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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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Kratochvílová S, Maratova K, Sumnik Z, Brunová J, Hlávka Z, Girman P, Saudek F, Soucek O. Increase in lumbar spine but not distal radius bone mineral density in adults after pancreas kidney transplantation. Bone Rep 2024; 21:101764. [PMID: 38681747 PMCID: PMC11046242 DOI: 10.1016/j.bonr.2024.101764] [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: 02/01/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 05/01/2024] Open
Abstract
Osteoporosis occurs in every third individual after simultaneous pancreas kidney transplantation (SPKT). Currently used bone measures insufficiently predict their fracture risk. Lumbar spine Trabecular bone score (TBS) and distal radius areal and volumetric bone mineral density (BMD) were monitored for the first time in patients with type 1 diabetes and chronic renal failure after SPKT with steroid-sparing protocol. In 33 subjects (mean age 43.4 ± 9.8 years), dual-energy X-ray absorptiometry and peripheral quantitative computed tomography were performed just after SPKT (baseline) and one and three years later. While TBS Z-scores increased (-1.1 ± 1.2 and -0.3 ± 1.0; p˂0.001, at baseline and year three, respectively), trabecular volumetric BMD Z-scores at distal radius metaphysis did not change during the study (-1.3 ± 1.3 and -1.3 ± 1.0; p = 0.38). Similarly, areal BMD Z-scores increased at lumbar spine, total hip and femoral neck (all p < 0.01), but not at the distal radius. SPKT induced bone measures' improvement at lumbar spine and hip but not at distal radius. Before suggesting changes in current clinical care, predictive value of individual bone measures or its combination for fracture risk assessment remains to be elucidated.
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Affiliation(s)
- Simona Kratochvílová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Klara Maratova
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jana Brunová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Zdeněk Hlávka
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Peter Girman
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - František Saudek
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ondrej Soucek
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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Yoon SH, Kim GY, Choi GT, Do JT. Organ Abnormalities Caused by Turner Syndrome. Cells 2023; 12:1365. [PMID: 37408200 DOI: 10.3390/cells12101365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/22/2023] [Accepted: 05/10/2023] [Indexed: 07/07/2023] Open
Abstract
Turner syndrome (TS), a genetic disorder due to incomplete dosage compensation of X-linked genes, affects multiple organ systems, leading to hypogonadotropic hypogonadism, short stature, cardiovascular and vascular abnormalities, liver disease, renal abnormalities, brain abnormalities, and skeletal problems. Patients with TS experience premature ovarian failure with a rapid decline in ovarian function caused by germ cell depletion, and pregnancies carry a high risk of adverse maternal and fetal outcomes. Aortic abnormalities, heart defects, obesity, hypertension, and liver abnormalities, such as steatosis, steatohepatitis, biliary involvement, liver cirrhosis, and nodular regenerative hyperplasia, are commonly observed in patients with TS. The SHOX gene plays a crucial role in short stature and abnormal skeletal phenotype in patients with TS. Abnormal structure formation of the ureter and kidney is also common in patients with TS, and a non-mosaic 45,X karyotype is significantly associated with horseshoe kidneys. TS also affects brain structure and function. In this review, we explore various phenotypic and disease manifestations of TS in different organs, including the reproductive system, cardiovascular system, liver, kidneys, brain, and skeletal system.
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Affiliation(s)
- Sang Hoon Yoon
- Department of Stem Cell and Regenerative Biotechnology, KU Institute of Technology, Konkuk University, Seoul 05029, Republic of Korea
| | - Ga Yeon Kim
- Department of Stem Cell and Regenerative Biotechnology, KU Institute of Technology, Konkuk University, Seoul 05029, Republic of Korea
| | - Gyu Tae Choi
- Department of Stem Cell and Regenerative Biotechnology, KU Institute of Technology, Konkuk University, Seoul 05029, Republic of Korea
| | - Jeong Tae Do
- Department of Stem Cell and Regenerative Biotechnology, KU Institute of Technology, Konkuk University, Seoul 05029, Republic of Korea
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Schweizer R, Mayer J, Binder G. Normal bone density but altered geometry in girls with Turner syndrome. J Pediatr Endocrinol Metab 2023; 36:270-277. [PMID: 36725676 DOI: 10.1515/jpem-2022-0516] [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: 10/10/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Data on bone density and stability in Turner syndrome (TS) are contradictory. A confounding factor for interpretation is short stature. The aim was to measure bone density, geometry and stability in girls with TS compared to idiopathic short stature (ISS). METHODS From 1999 to 2008, 59 girls with TS (35 prepubertal) were evaluated by pQCT. Mean age was 8.9 in prepubertal and 17.3 years in adolescent girls. Mean height was -3.1 and -1.8 SDS in prepubertal treatment-free and in adolescent, formerly rhGH-treated girls. For comparison, 18 prepubertal ISS girls were studied (age 7.7 years; height -3.3 SDS). Examination of radius with pQCT (XCT 2000). Cortical (CD) and trabecular density (TD), total bone area (TBA), cortical area (CA), cortical thickness, muscle area and strength strain index (SSI) were determined and compared with height related references. RESULTS In prepubertal girls with TS, TD and CD were normal (0.55 and 0.90 SDS) and comparable to ISS (0.95 and 1.53 SDS). TBA was greater in girls with TS than in ISS (0.87 vs. -0.33 SDS) whereas CA was similar (1.48 vs. 1.43 SDS). The SSI was comparable (1.61 vs. 1.56 SDS). Adolescent girls with TS showed similar results with a TD of 0.48 SDS, a CD of -0.32, TBA of 1.99, a CA of -0.05 and an SSI of 0.88 SDS. CONCLUSIONS The observations are consistent with normal bone density and stability but altered bone geometry in prepubertal and substituted adolescent girls with TS. This peculiarity may reflect SHOX deficiency. We therefore think that timely and adequate estrogen substitution could prevent bone loss in TS.
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Affiliation(s)
- Roland Schweizer
- University Children's Hospital, Pediatric Endocrinology, Tübingen, Germany
| | - Judith Mayer
- University Children's Hospital, Pediatric Endocrinology, Tübingen, Germany
| | - Gerhard Binder
- University Children's Hospital, Pediatric Endocrinology, Tübingen, Germany
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Skeletal Characteristics of Children and Adolescents with Turner Syndrome. ENDOCRINES 2022. [DOI: 10.3390/endocrines3030038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Turner syndrome (TS) is a chromosomal disorder characterized by a short stature and gonadal dysgenesis, the latter of which requires estrogen replacement therapy (ERT) to induce and maintain secondary sexual characteristics. Insufficient ERT is associated with compromised skeletal health, including bone fragility, in adults with TS. In particular, estrogen insufficiency during adolescence is critical because the acquisition of a defective bone mass during this period results in impaired bone strength later in the life. In addition to bone mass, bone geometry is also a crucial factor influencing bone strength; therefore, a more detailed understanding of the skeletal characteristics of both bone mass and geometry during childhood and adolescence and their relationships with the estrogen status is needed to prevent compromised skeletal health during adulthood in TS. Although a delay in the initiation of ERT is associated with a lower bone mineral density during adulthood, limited information is currently available on the effects of ERT during adolescence on bone geometry. Herein, we summarize the current knowledge on skeletal characteristics in children and adolescents with TS and their relationships with estrogen sufficiency, and discuss the potential limitations of the current protocol for ERT during adolescence in order to achieve better skeletal health in adulthood.
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 100] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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Ikegawa K, Hasegawa Y. Fracture risk, underlying pathophysiology, and bone quality assessment in patients with Turner syndrome. Front Endocrinol (Lausanne) 2022; 13:967857. [PMID: 36325455 PMCID: PMC9618639 DOI: 10.3389/fendo.2022.967857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/29/2022] [Indexed: 11/27/2022] Open
Abstract
Turner syndrome (TS), the most common type of X chromosomal disorder, has various, clinical manifestations. Among these, primary hypogonadism, which may lead to osteoporosis, is a life-long health issue. A high prevalence of fractures associated with osteoporosis is a major problem in patients with TS, where it may be 1.4-2.2 times higher than in healthy individuals and increases with age. Among the risk factors associated with fractures in TS, hypogonadism is arguably the most important. Estrogen deficiency due to hypogonadism leads to low bone mineral density (BMD), resulting in a high prevalence of bone fractures. Estrogen replacement therapy (ERT) in patients with TS reportedly improved their BMD. However, other causes of low BMD may exist, given that this condition begins in the prepubertal period in patients with TS. Most previous studies have reported low BMD in patients with TS using dual-energy X-ray absorptiometry (DXA), but this method has some limitations. Areal BMD values assessed by DXA were influenced by bone size and short stature, resulting in an underestimation of BMD. Currently, volumetric BMD values may be accurately obtained using peripheral quantitative computed tomography (pQCT). pQCT, high-resolution pQCT, and the trabecular bone score can also be used to evaluate bone quality, including bone geometry and microarchitecture, in TS. The present review discusses the high fracture risk, role of estrogen deficiency in low BMD, advantages and disadvantages of various bone assessment methods, and characteristics of bone quality in TS.
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Affiliation(s)
- Kento Ikegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Clinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- *Correspondence: Kento Ikegawa,
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Department of Pediatrics, Keio University of School of Medicine, Tokyo, Japan
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Zhang Y, Yang Y, Li P, Guo S. Origin of the X-chromosome influences the development and treatment outcomes of Turner syndrome. PeerJ 2021; 9:e12354. [PMID: 34966569 PMCID: PMC8667718 DOI: 10.7717/peerj.12354] [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] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 09/29/2021] [Indexed: 11/21/2022] Open
Abstract
Turner syndrome (TS) affects 1/2,500 live-born female infants. In the present study, we attempted to clarify the relationship between genetic factors (especially the X-chromosome origin), clinical features, body/sexual development, and treatment outcomes. We enrolled 39 female infants aged between 3 and 14 years. General demographic and clinical features were documented, and laboratory analysis of blood samples was performed. Subject karyotype was determined by G-banding of 50 peripheral white blood cells, and the parenteral origin of the retained X-chromosome was determined. Next, growth hormone (GH) treatment was prescribed for 12 months, with follow-ups performed as determined. For patient groups separated according to X-chromosome origin, the basal height, bone age, insulin-like growth factor (IGF)-1, and insulin-like growth factor binding protein-3 (IGFBP-3) levels were comparable; however, after the 12-month treatment, significant differences in the height increase and IGF-1 levels were observed. If the X-chromosome (or chromosomes) originated from both parents, the increase in height was less substantial, with lower serum IGF-1 levels. The uterine size, prolactin level, increased weight after treatment, and bone age difference after treatment negatively correlated with the mother's age at the time of birth. The mother's height at the time of birth demonstrated a negative correlation with the basal bone age difference and a positive correlation with the IGF-1 level. In summary, the retained X-chromosome derived from both parents is associated with poorer response to GH therapy. The mother's age and height at the time of birth can strongly impact the patient's body/sexual development and the response to GH treatment. Thus, the mother's age and height at the time of birth and the parental origin of the X-chromosome should be carefully considered before developing a treatment plan for TS.
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Affiliation(s)
- Ying Zhang
- Department of Endocrinology, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Yongchen Yang
- Department of Laboratory Medicine, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Sheng Guo
- Department of Endocrinology, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China
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Dallago RT, Marmo DB, Morcillo AM, Guerra Júnior G, Santos ADO, Galon MV, Lemos-Marini SHVD. The bone densitometry is normal in Turner syndrome prepubertal patients after height age correction. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2021. [DOI: 10.1590/1806-93042021000400010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Abstract Objectives: to evaluate the bone mass in prepubertal patients with Turner Syndrome (TS) according to height age (HA) and verify the influence of karyotype and adiposity. Methods: retrospective and analytical study of prepubertal TS patients. The variables analyzed were: karyotype, age at bone densitometry (BD), height, body mass index (BMI) and BD result. The result of the BD was corrected using HA. BMI and BD were calculated on Z score for chronological age (CA) and for HA. Results: thirty-seven prepubertal patients were selected and after exclusion criteria, 13 cases between 10 and 13 years old were included in the study. The BD for HA was significantly higher than for CA (0.39 ± 1.18 x −1.62 ± 1.32), without karyotype (p=0.369) and BMI (p=0.697) influence. Conclusion: prepubertal TS patients present normal BD when corrected for HA, without influence of karyotype and BMI.
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Samad N, Nguyen HH, Ebeling PR, Milat F. Musculoskeletal Health in Premature Ovarian Insufficiency. Part Two: Bone. Semin Reprod Med 2021; 38:289-301. [PMID: 33784746 DOI: 10.1055/s-0041-1722849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Accelerated bone loss and muscle loss coexist in women with premature ovarian insufficiency (POI), but there are significant gaps in our understanding of musculoskeletal health in POI. This review describes estrogen signaling in bone and its role in skeletal health and disease. Possible mechanisms contributing to bone loss in different forms of POI and current evidence regarding the utility of available diagnostic tests and therapeutic options are also discussed. A literature review from January 2000 to March 2020 was conducted to identify relevant studies. Women with POI experience significant deterioration in musculoskeletal health due to the loss of protective effects of estrogen. In bone, loss of bone mineral density (BMD) and compromised bone quality result in increased fracture risk; however, tools to assess bone quality such as trabecular bone score (TBS) need to be validated in this population. Timely initiation of HRT is recommended to minimize the deleterious effects of estrogen deficiency on bone in the absence of contraindications; however, the ideal estrogen replacement regimen remains unknown. POI is associated with compromised bone health, regardless of the etiology. Ongoing research is warranted to refine our management strategies to preserve bone health in women with POI.
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Affiliation(s)
- Navira Samad
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria, Australia.,Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria, Australia
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria, Australia
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Association between forearm cortical bone properties and handgrip strength in women with distal radius fractures: A cross-sectional study. PLoS One 2020; 15:e0243294. [PMID: 33270744 PMCID: PMC7714147 DOI: 10.1371/journal.pone.0243294] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/19/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Mechanical and biochemical bone properties are influenced by muscles. However, the muscle-bone interaction has not been fully elucidated regarding the upper extremities. The objective of the present study was to evaluate the mechanical muscle-bone interaction at the forearm by evaluating the relationship between the properties of three-dimensional (3D) forearm cortical bone models derived from conventional computed tomography (CT) images and handgrip strength (HGS). METHODS A total of 108 women (mean age, 75.2 ± 9.4 years; range, 62-101 years) with a distal radius fracture who took conventional CT scans for the assessment of the fracture were included in this study. Distal radius 3D models were reconstructed and the average cortical bone density (Cd) and thickness (Ct) of the region of interest (ROI), which might be affected by the forearm flexor muscles, were calculated using a 3D modeling software. Clinical parameters including HGS, lumbar and hip bone mineral densities (BMDs), and other demographic factors were also obtained. A multivariate linear regression analysis was performed to identify relevant factors associated with HGS. RESULTS HGS was found to be independently associated with height and Cd, but no significant difference was found between HGS and Ct, age, weight, as well as lumber and hip BMDs. CONCLUSIONS Cortical bone density might be associated with HGS, which is generated by the forearm flexor muscles. Hence, the mechanical muscle-bone interaction in the upper extremities could be supported by the present study.
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12
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Cardona Attard C, Cameron-Pimblett A, Puri D, Elliot J, Wilson JC, Talaulikar VS, Davies MC, Conway GS. Fracture rate in women with oestrogen deficiency - Comparison of Turner syndrome and premature ovarian insufficiency. Clin Endocrinol (Oxf) 2019; 91:743-749. [PMID: 31612507 DOI: 10.1111/cen.14110] [Citation(s) in RCA: 5] [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: 04/19/2019] [Revised: 10/01/2019] [Accepted: 10/13/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Women with early-onset oestrogen deficiency are at risk of reduced bone mineral density (BMD). We sought to assess fracture history and BMD in women with Turner syndrome (TS) and premature ovarian insufficiency (POI). DESIGN A cross-sectional observational study. PATIENTS Two hundred and sixty seven women with TS (median age 34.3 years) and 67 women with POI (median age 28.1 years). MEASUREMENTS A questionnaire was used to collect data on fracture history, co-morbidities and drug history including age at first oestrogen exposure. Clinical data included height, weight, serum vitamin D and hip and spine T-scores, which were adjusted for height and age. Fractures were subdivided into major osteoporotic fractures (MOF) and 'other' fracture types. RESULTS Overall fracture rate was similar in women with TS and POI (82 [30.5%] vs 22 [32.8%] respectively, P = .74). Compared to women with POI, those with TS had more fractures at MOF sites (30.2% vs 52.7%, P = .012) and fewer phalangeal fractures (27.9% vs 9.8%, P = .005). There was no difference in BMD between women who sustained a fracture compared to those who did not. Women with TS who fractured were more likely to suffer from hearing impairment compared to those with no fracture (62.2% vs 48.1%, P = .045). CONCLUSIONS TS is not associated with an overall excess risk of bone fracture. The higher rate of fractures at MOF sites in women with TS may be secondary to hearing impairment, thin cortical bone and abnormal bone remodelling.
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Affiliation(s)
| | | | - Davina Puri
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | - Jessica Elliot
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | - Jack C Wilson
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | | | - Melanie C Davies
- Reproductive Medicine Unit, University College London Hospitals, London, UK
| | - Gerard S Conway
- Reproductive Medicine Unit, University College London Hospitals, London, UK
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13
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Abstract
Turner syndrome is one of the most common sex chromosomal anomalies, characterized by the complete or partial loss of one X chromosome. Females with Turner syndrome are characterized by skeletal abnormalities, short stature and primary ovarian insufficiency. The aim of this narrative review was to identify the underlying mechanisms of osteoporosis in Turner syndrome, summarize its clinical manifestations and provide suggestions regarding the management of osteoporosis. Girls and women with Turner syndrome have lower bone mineral density and a higher fracture rate than healthy individuals. The most important risk factors for osteoporosis are inadequately treated primary ovarian insufficiency, followed by intrinsic bone abnormalities. Comorbidities that further increase the risk of osteoporosis include vitamin D deficiency, celiac disease and inflammatory bowel disease. In addition, hearing problems can predispose to falls. Early initiation of hormone replacement therapy (HRT) at the age of 11-13 years, prompt titration to the adult dose after 2 years and long-term follow-up to ensure compliance with HRT are the cornerstones of osteoporosis prevention in women with Turner syndrome.
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14
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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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15
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Nguyen HH, Wong P, Strauss BJ, Ebeling PR, Milat F, Vincent A. A Cross-Sectional and Longitudinal Analysis of Trabecular Bone Score in Adults With Turner Syndrome. J Clin Endocrinol Metab 2018; 103:3792-3800. [PMID: 30020460 DOI: 10.1210/jc.2018-00854] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/12/2018] [Indexed: 02/13/2023]
Abstract
CONTEXT Turner syndrome (TS) is associated with short stature, gonadal failure, and fractures. Spinal trabecular bone score (TBS) is a novel bone imaging modality that has not been evaluated in TS. OBJECTIVE To evaluate TBS in TS and its association with bone mineral density (BMD), prevalent fracture, and risk factors. DESIGN AND SETTING Longitudinal study of TS from a single tertiary hospital between 2006 and 2017. PATIENTS OR OTHER PARTICIPANTS Fifty-eight subjects with TS aged 20 to 49 years who underwent dual-energy X-ray absorptiometry (DXA). MAIN OUTCOME MEASURES TBS, DXA parameters, and prevalent fractures were investigated. RESULTS Normal, partially degraded, and degraded TBSs were observed in 39 (67%), 15 (26%), and four (7%) subjects, respectively. High rates of prescribed estrogen replacement therapy (ERT) with stable TBS and BMD were observed during follow-up. TBS was positively correlated with spine and femoral neck (FN) BMD and Z-scores (all P < 0.05) and negatively correlated with age (-0.004 per year; P = 0.014) and delay in ERT initiation in women with primary amenorrhea (-0.010 per year; P < 0.001). Fractures were present in 17 (31%) subjects. Low TBS had a significantly higher area under the receiver operator curve for predicting prevalent fracture than low bone mass at either the spine or FN (P < 0.05). Subjects with no history of fracture were more likely to have a normal TBS (P = 0.023). CONCLUSIONS BMD and TBS can be preserved with early initiation and continued use of ERT. TBS may provide additional fracture risk prediction to standard DXA parameters in TS and needs to be validated in larger prospective studies.
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Affiliation(s)
- Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Boyd J Strauss
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Amanda Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia
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16
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Kosteria I, Kanaka-Gantenbein C. Turner Syndrome: transition from childhood to adolescence. Metabolism 2018; 86:145-153. [PMID: 29309748 DOI: 10.1016/j.metabol.2017.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/29/2017] [Accepted: 12/31/2017] [Indexed: 01/15/2023]
Abstract
Transition from pediatric to adult care for young women with Turner Syndrome (TS) is characterized by high drop-out rates and inadequate follow-up, leading to increased morbidity and mortality. The complexity of the health issues young women with TS face or new problems that may arise warrants a well-structured and efficiently coordinated gradual transition plan, which is adapted to the individual needs of the emerging young adult and is based on interdisciplinary communication between physicians. In order to achieve a high level of care, it is important for the patient to be sincerely informed about her condition but also supported throughout this critical period of rising responsibility and autonomy by an experienced, multidisciplinary team. In this review, we present the basic concepts that should characterize transition and the major health issues that should be thoroughly addressed, including growth, Hormone Replacement Treatment and fertility options, cardiovascular disease, bone health, gastrointestinal disorders, autoimmunity, orthopaedic and ENT issues, as well as the overall psychological well-being of the young adult with TS.
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Affiliation(s)
- Ioanna Kosteria
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece.
| | - Christina Kanaka-Gantenbein
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece
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17
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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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18
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Wasserman H, Backeljauw PF, Khoury JC, Kalkwarf HJ, Gordon CM. Bone fragility in Turner syndrome: Fracture prevalence and risk factors determined by a national patient survey. Clin Endocrinol (Oxf) 2018; 89:46-55. [PMID: 29658144 DOI: 10.1111/cen.13614] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Osteoporosis is considered a comorbidity of adult women with Turner syndrome (TS). Limited data are available on fracture prevalence in girls and women with this diagnosis. We aimed to determine the prevalence of fractures in individuals with TS in the United States and identify risk factors for fracture. DESIGN Girls and women with TS were invited to participate in an anonymous, self-report, national survey from November 2016 to March 2017. Non-TS controls were obtained through direct contacts of TS participants. RESULTS During childhood (0-12 years), adolescence (13-25 years) and young adulthood (26-45 years), there was no difference between TS and controls in fracture prevalence. Girls and women with TS were more likely to report upper extremity fractures, whereas controls were more likely to report phalangeal fractures. Older women (>45 years) with TS were more likely to fracture than non-TS controls (P = .01). Balance problems were more common in individuals with TS than controls (26.5% vs 14.8%, P = .0006). In TS, those reporting balance problems were 54% more likely to have a prior fracture than those without balance problems (OR=1.54, 95% CI 1.03, 2.30), even after controlling for age. There was no significant association between balance problems and fractures among controls. CONCLUSIONS In a nationwide survey, there was no difference in fracture prevalence in younger women with TS compared with controls. However, the location of fractures differed. After controlling for age, impaired balance was associated with an increased fracture risk in TS and may be an underrecognized risk factor for fracture in this population.
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Affiliation(s)
- Halley Wasserman
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Philippe F Backeljauw
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Heidi J Kalkwarf
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Catherine M Gordon
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Adolescent and Transition Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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19
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Soucek O, Schönau E, Lebl J, Willnecker J, Hlavka Z, Sumnik Z. A 6-Year Follow-Up of Fracture Incidence and Volumetric Bone Mineral Density Development in Girls With Turner Syndrome. J Clin Endocrinol Metab 2018; 103:1188-1197. [PMID: 29300907 DOI: 10.1210/jc.2017-02381] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/20/2017] [Indexed: 02/03/2023]
Abstract
CONTEXT Patients with Turner syndrome (TS) are at risk for osteoporotic fractures. OBJECTIVE The aims of this study were to assess the incidence of clinically important fractures in girls with TS and prospectively describe the development of volumetric bone mineral density (BMD). DESIGN Peripheral quantitative computerized tomography (pQCT) of the radius every other year over the 6 years of observation. SETTING Government-funded university referral center. PARTICIPANTS Thirty-two girls with TS, aged 6 to 16 years, were included in the analyses. Fracture incidence was compared with the data in the general population. Bone density and strength were compared with data from 185 healthy girls. OUTCOMES The main clinical outcome was the fracture occurrence. The secondary outcomes were the changes in Z-scores of the bone parameters. RESULTS Three girls with TS sustained four fractures during 6 years of observation. The fracture rate in TS was not substantially higher than the downward-biased fracture-rate estimate from age-matched, healthy controls (P = 0.48). Whereas the trabecular BMD Z-score decreased with age (β estimate -0.21 ± 0.04, P < 0.001), total bone cross-sectional area correspondingly increased (+0.16 ± 0.04, P < 0.001), which led to normal bone strength. A positive history of incident fractures was not significantly associated with any of the pQCT-derived bone parameters. CONCLUSIONS Current pediatric TS patients that are treated with growth hormone and estrogens are not at risk for osteoporotic fractures. Low BMD in TS may be counterweighted by enlarged bone radius, which leads to normal bone strength at the appendicular skeleton.
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Affiliation(s)
- Ondrej Soucek
- Department of Pediatrics, Second Medical Faculty, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Eckhard Schönau
- Department of Pediatrics, University Hospital Cologne and Cologne University, Cologne, Germany
| | - Jan Lebl
- Department of Pediatrics, Second Medical Faculty, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | - Zdenek Hlavka
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University in Prague, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, Second Medical Faculty, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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20
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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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21
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Abstract
Identifying children most susceptible to clinically significant fragility fractures (low trauma fractures or vertebral compression fractures) or recurrent fractures is an important issue facing general pediatricians and subspecialists alike. Over the last decade, several imaging technologies, including dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, have become useful to identify abnormal bone mineralization in children and in adolescents. This review aimed to summarize the latest literature on the utility of these modalities as they pertain to use in pediatrics. In addition, we review several disease states associated with poor bone health and increased fracture risk in children, and discuss the implications of low bone mineral density in these patients. Finally, we will highlight the gaps in knowledge with regard to pediatric bone health and make recommendations for future areas of research.
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Affiliation(s)
- Halley Wasserman
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Catherine M Gordon
- Divisions of Adolescent Medicine and Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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22
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Nguyen HH, Wong P, Strauss BJ, Jones G, Ebeling PR, Milat F, Vincent A. Delay in estrogen commencement is associated with lower bone mineral density in Turner syndrome. Climacteric 2017; 20:436-441. [DOI: 10.1080/13697137.2017.1325461] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- H. H. Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
| | - P. Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - B. J. Strauss
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - G. Jones
- Menzies Institute of Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - P. R. Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
| | - F. Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - A. Vincent
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, VIC, Australia
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23
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Hasegawa Y, Ariyasu D, Izawa M, Igaki-Miyamoto J, Fukuma M, Hatano M, Yagi H, Goto M. Gradually increasing ethinyl estradiol for Turner syndrome may produce good final height but not ideal BMD. Endocr J 2017; 64:221-227. [PMID: 27916781 DOI: 10.1507/endocrj.ej16-0170] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Estrogen replacement therapy in Turner syndrome should theoretically mimic the physiology of healthy girls. The objective of this study was to describe final height and bone mineral density (BMD) in a group of 17 Turner syndrome patients (group E) who started their ethinyl estradiol therapy with an ultra-low dosage (1-5 ng/kg/day) from 9.8-13.7 years. The subjects in group E had been treated with GH 0.35 mg/kg/week since the average age of 7.4 years. The 30 subjects in group L, one of the historical groups, were given comparable doses of GH, and conjugated estrogen 0.3125 mg/week ∼0.3125 mg/day was initiated at 12.2-18.7 years. The subjects in group S, the other historical group, were 21 patients who experienced breast development and menarche spontaneously. Final height (height gain < 2 cm/year) in group E was 152.4 ± 3.4 cm and the standard deviation (SD) was 2.02 ± 0.62 for Turner syndrome. The final height in group L was 148.5 ± 3.0 cm with a SD of 1.30 ± 0.55, which was significantly different from the values for group E. The volumetric BMD of group S (0.290 ± 0.026 g/cm3) was significantly different from that of group L or E (0.262 or 0.262 g/cm3 as a mean, respectively). This is the first study of patients with Turner syndrome where estrogen was administered initially in an ultra-low dose and then increased gradually. Our estrogen therapy in group E produced good final height but not ideal BMD.
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Affiliation(s)
- Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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24
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Cleemann L, Holm K, Kobbernagel H, Kristensen B, Skouby SO, Jensen AK, Gravholt CH. Dosage of estradiol, bone and body composition in Turner syndrome: a 5-year randomized controlled clinical trial. Eur J Endocrinol 2017; 176:233-242. [PMID: 27881458 DOI: 10.1530/eje-16-0582] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 11/11/2016] [Accepted: 11/23/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Reduced bone mineral density (BMD) is seen in Turner syndrome (TS) with an increased risk of fractures, and body composition is characterized by increased body fat and decreased lean body mass. To evaluate the effect of two different doses of oral 17B-estradiol in young TS women on bone mineral density (BMD), biochemical markers of bone turnover and body composition with the hypothesis of a positive effect of the higher dose. DESIGN A double-blind 5-year randomized controlled clinical trial. 20 young TS women participated. Inclusion criteria were diagnosis of TS, age 15-25 years and current treatment with 2 mg oral estradiol daily. METHODS The low-dose (LD) group was administered 2 mg 17B-estradiol/day orally and placebo, the high-dose (HD) group was administered 2 + 2 mg 17B-estradiol/day orally. Main outcome measures were whole body and regional bone mineral density (BMD), lean body mass (LBM), fat mass (FM) measured yearly by DXA scan and resorptive and formative bone markers in serum. RESULTS BMD, whole body and regional, increased over time with an attenuation toward the end of the study, and bone turnover markers decreased over time, both with no differences between the treatment groups (P = 0.2-0.9). LBM increased significantly more in the HD group (P = 0.02). FM remained stable in both groups. CONCLUSIONS A steady increase in BMD over time in TS was found similar to healthy young women. The higher estrogen dose did not differentially affect BMD or bone markers. The positive effect on body composition may have long-ranging health benefits in TS.
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Affiliation(s)
| | | | | | - Bent Kristensen
- Department of RadiologyNordsjællands Hospital, Hillerød, Denmark
| | - Sven Oluf Skouby
- Department of Gynecology and ObstetricsHerlev University Hospital, Herlev, Denmark
| | - Andreas Kryger Jensen
- Center of Research and InnovationNordsjællands Hospital, Hillerød, Denmark
- Department of Public HealthUniversity of Copenhagen, Copenhagen, Denmark
| | - Claus H Gravholt
- Department of Endocrinology and Internal Medicine and the Medical Research LaboratoriesAarhus Sygehus NBG, Aarhus University Hospital, Aarhus C, Denmark
- Department of Molecular MedicineAarhus University Hospital, Aarhus N, Denmark
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Gawlik A, Hankus M, Such K, Drosdzol-Cop A, Madej P, Borkowska M, Zachurzok A, Malecka-Tendera E. Hypogonadism and Sex Steroid Replacement Therapy in Girls with Turner Syndrome. J Pediatr Adolesc Gynecol 2016; 29:542-550. [PMID: 27018757 DOI: 10.1016/j.jpag.2016.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/06/2016] [Accepted: 03/09/2016] [Indexed: 12/28/2022]
Abstract
Turner syndrome is the most common example of hypergonadotropic hypogonadism resulting from gonadal dysgenesis. Most patients present delayed, or even absent, puberty. Premature ovarian failure can be expected even if spontaneous menarche occurs. Laboratory markers of gonadal dysgenesis are well known. The choice of optimal hormone replacement therapy in children and adolescents remains controversial, particularly regarding the age at which therapy should be initiated, and the dose and route of estrogen administration. On the basis of a review of the literature, we present the most acceptable schedule of sex steroid replacement therapy in younger patients with Turner syndrome.
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Affiliation(s)
- Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland.
| | - Magdalena Hankus
- Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
| | - Kamila Such
- Medical Students' Scientific Association, Katowice, Poland
| | | | - Paweł Madej
- Department of Endocrinological Gynecology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | - Agnieszka Zachurzok
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
| | - Ewa Malecka-Tendera
- Department of Pediatrics and Pediatric Endocrinology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland; Department of Pediatrics, Pediatric Endocrinology and Diabetes, Upper-Silesian Pediatric Health Center, Katowice, Poland
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Shi K, Liu L, He YJ, Li D, Yuan LX, Lash GE, Li L. Body composition and bone mineral status in patients with Turner syndrome. Sci Rep 2016; 6:38026. [PMID: 27901060 PMCID: PMC5128814 DOI: 10.1038/srep38026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 11/04/2016] [Indexed: 01/15/2023] Open
Abstract
Turner syndrome (TS) is associated with decreased bone mineral density and increased fracture rate. However, the developmental trajectory of bone density or body composition in patients with TS is still unclear. The present study tested the hypothesis that different karyotypes and/or age contributes to abnormal body composition and decreased bone mineral status parameters in patients with TS. This study included 24 girls with TS, in which 13 girls exhibited X0 karyotype and 11 had mosaicism. Quantitative ultrasound (QUS) assessed the bone mineral status of the calcaneus, including bone mineral density (BMD), amplitude-dependent speed of sound (AD-SOS), broadband ultrasound attenuation (BUA) and InBody 770 assessed body composition. Pearson's test was performed to correlate measured parameters with patient age. The body composition and bone mineral status parameters were not significantly influenced by patient karyotype. There was a correlation between patient age and AD-SOS (r = -0.61, P = 0.002) and BUA (r = 0.50, P = 0.013) but not BMD (r = -0.19, P = 0.379). In conclusion, there was no effect of karyotype on body composition or body mineral status. Bone mineral status, as evidenced by changes in AD-SOS and BUA, alters with age regardless of karyotype. The developmental trajectory demonstrated in the current study warrants further validation in a longitudinal study.
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Affiliation(s)
- Kun Shi
- Department of Gynecology and Obstetrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, 9 Jingsui Road, Guangzhou, Guangdong, 510160, China
| | - Li Liu
- Department of Pediatrics Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, 9 Jingsui Road, Guangzhou, Guangdong 510160, China
| | - Yao-Juan He
- Department of Gynecology and Obstetrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, 9 Jingsui Road, Guangzhou, Guangdong, 510160, China
| | - Duan Li
- Department of Pediatrics Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, 9 Jingsui Road, Guangzhou, Guangdong 510160, China
| | - Lian-Xiong Yuan
- Department of Biostatistics, Sun Yixian University, 74 Zhong Shan Er Road, Guangzhou, Guangdong, 510515, China
| | - Gendie E. Lash
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, 9 Jingsui Road, Guangzhou, Guangdong, 510160, China
| | - Li Li
- Department of Gynecology and Obstetrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, 9 Jingsui Road, Guangzhou, Guangdong, 510160, China
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Sherif HM. Turner syndrome and guidelines for management of thoracic aortic disease: Appropriateness and utility. Artery Res 2016. [DOI: 10.1016/j.artres.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Nour MA, Burt LA, Perry RJ, Stephure DK, Hanley DA, Boyd SK. Impact of Growth Hormone on Adult Bone Quality in Turner Syndrome: A HR-pQCT Study. Calcif Tissue Int 2016; 98:49-59. [PMID: 26439721 DOI: 10.1007/s00223-015-0064-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/24/2015] [Indexed: 02/06/2023]
Abstract
Women with Turner syndrome (TS) are known to be at risk of osteoporosis. While childhood growth hormone (GH) treatment is common in TS, the impact of this therapy on bone health has been poorly understood. The objective of this study was to determine the influence of childhood GH treatment on adult bone quality in women with TS. 28 women aged 17-45 with confirmed TS (12 GH-treated) agreed to participate in this cross-sectional study. Dual X-ray absorptiometry (DXA) of lumbar spine, hip, and radius and high-resolution peripheral quantitative computed tomography (HR-pQCT) scans of the radius and tibia were used to determine standard morphological and micro-architectural parameters of bone health. Finite element (FE) analysis and polar moment of inertia (pMOI) were used to estimate bone strength. GH-treated subjects were +7.4 cm taller (95% CI 2.5-12.3 cm, p = 0.005). DXA-determined areal BMD of hip, spine, and radius was similar between treatment groups. Both tibial and radial total bone areas were greater among GH-treated subjects (+20.4 and +21.2% respectively, p < 0.05), while other micro-architectural results were not different between groups. pMOI was significantly greater among GH-treated subjects (radius +35.0%, tibia +34.0%, p < 0.05). Childhood GH treatment compared to no treatment in TS was associated with an increased height, larger bones, and greater pMOI, while no significant difference in DXA-derived BMD, HR-pQCT micro-architectural parameters, or FE-estimated bone strength was detected. The higher pMOI and greater bone size may confer benefit for fracture reduction in these GH-treated patients.
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Affiliation(s)
- Munier A Nour
- Department of Pediatrics, University of Saskatchewan, Saskatoon, SK, Canada
- Division of Pediatric Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
| | - Lauren A Burt
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Rebecca J Perry
- Division of Pediatric Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David K Stephure
- Division of Pediatric Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David A Hanley
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Steven K Boyd
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Radiology, University of Calgary, Calgary, AB, Canada.
- McCaig Institute for Bone and Joint Health, University of Calgary, Room HRIC 3AC64, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Faienza MF, Ventura A, Colucci S, Cavallo L, Grano M, Brunetti G. Bone Fragility in Turner Syndrome: Mechanisms and Prevention Strategies. Front Endocrinol (Lausanne) 2016; 7:34. [PMID: 27199891 PMCID: PMC4844601 DOI: 10.3389/fendo.2016.00034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/11/2016] [Indexed: 01/18/2023] Open
Abstract
Bone fragility is recognized as one of the major comorbidities in Turner syndrome (TS). The mechanisms underlying bone impairment in affected patients are not clearly elucidated, but estrogen deficiency and X-chromosomal abnormalities represent important factors. Moreover, although many girls with TS undergo recombinant growth hormone therapy to treat short stature, the efficacy of this treatment on bone mineral density is controversial. The present review will focus on bone fragility in subjects with TS, providing an overview on the pathogenic mechanisms and some prevention strategies.
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Affiliation(s)
- Maria Felicia Faienza
- Pediatrics Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “A. Moro”, Bari, Italy
| | - Annamaria Ventura
- Pediatrics Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “A. Moro”, Bari, Italy
| | - Silvia Colucci
- Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari “A. Moro”, Bari, Italy
| | - Luciano Cavallo
- Pediatrics Unit, Department of Biomedical Sciences and Human Oncology, University of Bari “A. Moro”, Bari, Italy
| | - Maria Grano
- Department of Emergency and Organ Transplantation (DETO), University of Bari “A. Moro”, Bari, Italy
| | - Giacomina Brunetti
- Section of Human Anatomy and Histology, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari “A. Moro”, Bari, Italy
- *Correspondence: Giacomina Brunetti,
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Soucek O, Matyskova J, Anliker E, Toigo M, Hlavka Z, Lebl J, Sumnik Z. The muscle-bone interaction in Turner syndrome. Bone 2015; 74:160-5. [PMID: 25659206 DOI: 10.1016/j.bone.2015.01.017] [Citation(s) in RCA: 9] [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: 09/28/2014] [Revised: 01/20/2015] [Accepted: 01/26/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Turner syndrome (TS) is associated with an increased fracture rate due to reduced bone strength, which is mainly determined by skeletal muscle force. This study aimed to assess the muscle force-bone strength relationship in TS and to compare it with that of healthy controls. METHODS This study included 39 girls with TS and 67 healthy control girls. Maximum muscle force (Fmax) was assessed through multiple one-legged hopping with jumping mechanography. Peripheral quantitative computerized tomography assessed the bone strength index at the tibial metaphysis (BSI 4) and the polar strength-strain index at the diaphysis (SSI polar 66). The effect of TS on the muscle-bone unit was tested using multiple linear regression. RESULTS TS had no impact on Fmax (p=0.14); however, a negative effect on bone strength (p<0.001 for BSI 4 and p<0.01 for SSI polar 66) was observed compared with healthy controls. Bone strength was lower in the TS group (by 18%, p<0.01, for BSI 4 and by 7%, p=0.027, for SSI polar 66), even after correcting for Fmax. CONCLUSIONS Similar muscle force induces lower bone strength in TS compared with healthy controls, which suggests altered bone-loading sensitivity in TS.
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Affiliation(s)
- Ondrej Soucek
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jana Matyskova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Elmar Anliker
- Clinic for Sports Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Marco Toigo
- Exercise Physiology Lab, Institute of Human Movement Sciences, ETH Zurich, Zurich, Switzerland
| | - Zdenek Hlavka
- Department of Statistics, Faculty of Mathematics and Physics, Charles University in Prague, Prague, Czech Republic
| | - Jan Lebl
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic.
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31
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Soucek O, Schönau E, Lebl J, Sumnik Z. Artificially low cortical bone mineral density in Turner syndrome is due to the partial volume effect. Osteoporos Int 2015; 26:1213-8. [PMID: 25288443 DOI: 10.1007/s00198-014-2901-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 09/09/2014] [Indexed: 12/15/2022]
Abstract
UNLABELLED We aimed to show that the decrease in the cortical bone mineral density (BMD) in the radius in Turner syndrome (TS) is artificially caused by the partial volume effect. We confirmed that the partial volume effect-corrected cortical BMD is not decreased in TS compared to in the healthy controls. Other factors are responsible for the increased fracture rate in TS. INTRODUCTION Decreased cortical bone mineral density (BMD) has been reported in Turner syndrome (TS), using peripheral quantitative computerised tomography, and it is perceived as one of the major factors leading to increased fracture risk. We tested the hypothesis that low cortical BMD in the radius is caused artificially by the partial volume effect. METHODS A cross-sectional study was conducted at the university hospital referral centre between March and October 2013. Thirty-two participants with TS who consented to the study were included (mean age 15.3 ± 3.2 years). We assessed the cortical BMD in the radius as well as the tibia, where the cortex is thicker compared with the radius. RESULTS Whereas the cortical BMD was decreased in the radius (mean ± SD Z-score -0.6 ± 1.5, p = 0.037), it was increased in the tibia (mean Z-score 0.83 ± 1.0, p < 0.001). After correcting the cortical BMD for the partial volume effect, the mean Z-score was normal in the radius in TS (0.4 ± 1.3, p = 0.064). The corrected cortical BMD values were similar in the radius and tibia (1108 ± 52 vs. 1104 ± 48, group difference p = 0.75). CONCLUSIONS The cortical BMD is not decreased in TS. The partial volume effect is responsible for previous findings of decreased cortical BMD in the radius. Altered bone geometry or other factors rather than low cortical BMD likely play a role in the increased fracture risk in TS.
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Affiliation(s)
- O Soucek
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Uvalu 84, 150 06, Praha 5, Czech Republic,
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Soucek O, Lebl J, Matyskova J, Snajderova M, Kolouskova S, Pruhova S, Hlavka Z, Sumnik Z. Muscle function in Turner syndrome: normal force but decreased power. Clin Endocrinol (Oxf) 2015; 82:248-53. [PMID: 24890376 DOI: 10.1111/cen.12518] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/04/2014] [Accepted: 05/27/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Although hypogonadism and SHOX gene haploinsufficiency likely cause the decreased bone mineral density and increased fracture rate associated with Turner syndrome (TS), the exact mechanism remains unclear. We tested the hypothesis that muscle dysfunction in patients with TS contributes to increased fracture risk. The secondary aim was to determine whether menarche, hormone therapy duration, positive fracture history and genotype influence muscle function parameters in patients with TS. DESIGN A cross-sectional study was conducted in a single university hospital referral centre between March 2012 and October 2013. PATIENTS Sixty patients with TS (mean age of 13·7 ± 4·5 years) were compared to the control group of 432 healthy girls. MEASUREMENTS A Leonardo Mechanograph(®) Ground Reaction Force Platform was used to assess muscle force (Fmax ) by the multiple one-legged hopping test and muscle power (Pmax ) by the single two-legged jump test. RESULTS While the Fmax was normal (mean weight-specific Z-score of 0·11 ± 0·77, P = 0·27), the Pmax was decreased in patients with TS (Z-score of -0·93 ± 1·5, P < 0·001) compared with healthy controls. The muscle function parameters were not significantly influenced by menarcheal stage, hormone therapy duration, fracture history or genotype (linear regression adjusted for age, weight and height; P > 0·05 for all). CONCLUSION Fmax , a principal determinant of bone strength, is normal in patients with TS. Previously described changes in bone quality and structure in TS are thus not likely related to inadequate mechanical loading but rather represent a primary bone deficit. A decreased Pmax indicates impaired muscle coordination in patients with TS.
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Affiliation(s)
- Ondrej Soucek
- Department of Paediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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Abstract
Although Turner syndrome is the most common chromosomal disorder in women, a great deal remains to be understood in terms of optimal patient care, particularly as it relates to bone health. These women are known to be at risk for osteoporosis and fracture later in life as a result of a multitude of risk factors. While estrogen replacement and childhood growth hormone treatment are now considered standard of care, little is known of the role of further interventions to prevent and treat osteoporosis in these women. This review aims to highlight the specifics of bone health in Turner syndrome. We explore the bone diagnostic modalities and therapeutic interventions available and their role in the coming years of bone health management in this unique population.
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Affiliation(s)
- Munier A Nour
- a Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rebecca J Perry
- b Division of Pediatric Endocrinology, Alberta Children's Hospital, Calgary, Alberta, Canada
- c Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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Identification of novel SHOX target genes in the developing limb using a transgenic mouse model. PLoS One 2014; 9:e98543. [PMID: 24887312 PMCID: PMC4041798 DOI: 10.1371/journal.pone.0098543] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 05/04/2014] [Indexed: 11/19/2022] Open
Abstract
Deficiency of the human short stature homeobox-containing gene (SHOX) has been identified in several disorders characterized by reduced height and skeletal anomalies such as Turner syndrome, Léri-Weill dyschondrosteosis and Langer mesomelic dysplasia as well as isolated short stature. SHOX acts as a transcription factor during limb development and is expressed in chondrocytes of the growth plates. Although highly conserved in vertebrates, rodents lack a SHOX orthologue. This offers the unique opportunity to analyze the effects of human SHOX expression in transgenic mice. We have generated a mouse expressing the human SHOXa cDNA under the control of a murine Col2a1 promoter and enhancer (Tg(Col2a1-SHOX)). SHOX and marker gene expression as well as skeletal phenotypes were characterized in two transgenic lines. No significant skeletal anomalies were found in transgenic compared to wildtype mice. Quantitative and in situ hybridization analyses revealed that Tg(Col2a1-SHOX), however, affected extracellular matrix gene expression during early limb development, suggesting a role for SHOX in growth plate assembly and extracellular matrix composition during long bone development. For instance, we could show that the connective tissue growth factor gene Ctgf, a gene involved in chondrogenic and angiogenic differentiation, is transcriptionally regulated by SHOX in transgenic mice. This finding was confirmed in human NHDF and U2OS cells and chicken micromass culture, demonstrating the value of the SHOX-transgenic mouse for the characterization of SHOX-dependent genes and pathways in early limb development.
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Bianchi ML, Leonard MB, Bechtold S, Högler W, Mughal MZ, Schönau E, Sylvester FA, Vogiatzi M, van den Heuvel-Eibrink MM, Ward L. Bone health in children and adolescents with chronic diseases that may affect the skeleton: the 2013 ISCD Pediatric Official Positions. J Clin Densitom 2014; 17:281-94. [PMID: 24656723 DOI: 10.1016/j.jocd.2014.01.005] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/10/2014] [Indexed: 12/11/2022]
Abstract
The aim of this Task Force was to review the use of dual-energy X-ray absorptiometry (DXA) in children and adolescents with underlying chronic diseases that pose risk factors for compromised bone health, such as inflammation, glucocorticoid therapy, or decreased mobility. The Task Force systematically analyzed more than 270 studies, with an emphasis on those published in the interval since the original 2007 Position Statements. Important developments over this period included prospective cohort studies demonstrating that DXA measures of areal bone mineral density (aBMD) predicted incident fractures and the development of robust reference data and strategies to adjust for bone size in children with growth impairment. In this report, we summarize the current literature on the relationship between DXA-based aBMD and both fracture (vertebral and non-vertebral) outcomes and non-fracture risk factors (e.g., disease characteristics, ambulatory status, and glucocorticoid exposure) in children with chronic illnesses. Most publications described the aBMD profile of children with underlying diseases, as well as the cross-sectional or longitudinal relationship between aBMD and clinically relevant non-fracture outcomes. Studies that addressed the relationship between aBMD and prevalent or incident fractures in children with chronic illnesses are now emerging. In view of these updated data, this report provides guidelines for the use of DXA-based aBMD in this setting. The initial recommendation that DXA is part of a comprehensive skeletal healthy assessment in patients with increased risk of fracture is unchanged. Although the prior guidelines recommended DXA assessment in children with chronic diseases at the time of clinical presentation with ongoing monitoring, this revised Position Statement focuses on the performance of DXA when the patient may benefit from interventions to decrease their elevated risk of a clinically significant fracture and when the DXA results will influence that management.
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Affiliation(s)
- Maria Luisa Bianchi
- Experimental Laboratory for Children's Bone Metabolism Research, Istituto Auxologico Italiano IRCCS, Milano, Italy.
| | - Mary B Leonard
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Susanne Bechtold
- Department of Pediatrics, Medical University Munich, Munich, Germany
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - M Zulf Mughal
- Department of Paediatric Medicine, Royal Manchester Children's Hospital, Manchester, UK
| | - Eckhart Schönau
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinik Köln, Köln, Germany
| | | | - Maria Vogiatzi
- Department of Pediatric Endocrinology, Weill Medical College of Cornell University, New York, NY, USA
| | | | - Leanne Ward
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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Adams JE, Engelke K, Zemel BS, Ward KA. Quantitative computer tomography in children and adolescents: the 2013 ISCD Pediatric Official Positions. J Clin Densitom 2014; 17:258-74. [PMID: 24792821 DOI: 10.1016/j.jocd.2014.01.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 12/24/2022]
Abstract
In 2007, International Society of Clinical Densitometry Pediatric Positions Task Forces reviewed the evidence for the clinical application of peripheral quantitative computed tomography (pQCT) in children and adolescents. At that time, numerous limitations regarding the clinical application of pQCT were identified, although its use as a research modality for investigation of bone strength was highlighted. The present report provides an updated review of evidence for the clinical application of pQCT, as well as additional reviews of whole body QCT scans of the central and peripheral skeletons, and high-resolution pQCT in children. Although these techniques remain in the domain of research, this report summarizes the recent literature and evidence of the clinical applicability and offers general recommendations regarding the use of these modalities in pediatric bone health assessment.
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Affiliation(s)
- Judith E Adams
- Department of Clinical Radiology, The Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, England, UK.
| | - Klaus Engelke
- Institute of Medical Physics, University of Erlangen, Erlangen, Germany and Synarc A/S, Germany
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kate A Ward
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
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Gawlik A, Malecka-Tendera E. Transitions in endocrinology: treatment of Turner's syndrome during transition. Eur J Endocrinol 2014; 170:R57-74. [PMID: 24225028 DOI: 10.1530/eje-13-0900] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Transition in health care for young patients with Turner's syndrome (TS) should be perceived as a staged but uninterrupted process starting in adolescence and moving into adulthood. As a condition associated with high risk of short stature, cardiovascular diseases, ovarian failure, hearing loss and hypothyroidism, TS requires the attention of a multidisciplinary team. In this review paper, we systematically searched the relevant literature from the last decade to discuss the array of problems faced by TS patients and to outline their optimal management during the time of transfer to adult service. The literature search identified 233 potentially relevant articles of which 114 were analysed. The analysis confirmed that all medical problems present during childhood should also be followed in adult life. Additionally, screening for hypertension, diabetes mellitus, dyslipidaemia, and osteoporosis is needed. After discharge from the paediatric clinic, there is still a long way to go.
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Affiliation(s)
- Aneta Gawlik
- Department of Paediatrics, Paediatric Endocrinology and Diabetes, Medical University of Silesia, ul Medykow 16, 40-752 Katowice, Poland
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Nadeem M, Roche EF. Bone mineral density in Turner's syndrome and the influence of pubertal development. Acta Paediatr 2014; 103:e38-42. [PMID: 24354573 DOI: 10.1111/apa.12435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 08/08/2013] [Accepted: 09/25/2013] [Indexed: 11/27/2022]
Abstract
AIM To describe bone mineral density at the lumbar spine in a group of girls with Turner's syndrome and determine its relation to pubertal development. METHODS Girls with Turner's syndrome aged over 12 years were invited to participate in the study. All participants underwent auxology, pubertal assessment and laboratory evaluation. Bone mineral density was estimated by dual-energy X-ray absorptiometry. Bone mineral apparent density was then calculated, and the results were compared with age-matched Dutch reference data. RESULTS We studied 32 girls with Turner's syndrome, mean (SD) [range] age 16.7 (2.6) [12.4-20.2] years and height 148.3 (9.0) [126-159.2] cm. Bone mineral apparent density lumbar spine values were -0.87 SD, significantly lower than in the reference population (p <0.001). Bone mineral apparent density values were positively and significantly associated with breast Tanner stages and postmenarcheal status, but not spontaneous puberty. However, no significant association was found between bone mineral apparent density and karyotype, growth hormone or timing of oestrogen therapy. CONCLUSION Girls with Turner's syndrome have lower bone mineral apparent density values at the lumbar spine, even after correcting for size, compared with an age- and sex-matched general population. Pubertal development has significant impact on bone mineral apparent density in girls with Turner's syndrome.
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Affiliation(s)
- Montasser Nadeem
- Department of Paediatrics; University of Dublin; Trinity College; National Children's Hospital; Tallaght Dublin Ireland
| | - Edna F Roche
- Department of Paediatrics; University of Dublin; Trinity College; National Children's Hospital; Tallaght Dublin Ireland
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Soucek O, Zapletalova J, Zemkova D, Snajderova M, Novotna D, Hirschfeldova K, Plasilova I, Kolouskova S, Rocek M, Hlavka Z, Lebl J, Sumnik Z. Prepubertal girls with Turner syndrome and children with isolated SHOX deficiency have similar bone geometry at the radius. J Clin Endocrinol Metab 2013; 98:E1241-7. [PMID: 23666967 DOI: 10.1210/jc.2013-1113] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
CONTEXT The low bone mineral density (BMD) and alterations in bone geometry observed in patients with Turner syndrome (TS) are likely caused by hypergonadotropic hypogonadism and/or by haploinsufficiency of the SHOX gene. OBJECTIVE Our objective was to compare BMD, bone geometry, and strength at the radius between prepubertal girls with TS and children with isolated SHOX deficiency (SHOX-D) to test the hypothesis that the TS radial bone phenotype may be caused by SHOX-D. DESIGN AND SETTING This comparative cross-sectional study was performed between March 2008 and May 2011 in 5 large centers for pediatric endocrinology. PATIENTS Twenty-two girls with TS (mean age 10.3 years) and 10 children with SHOX-D (mean age 10.3 years) were assessed using peripheral quantitative computed tomography of the forearm. MAIN OUTCOMES BMD, bone geometry, and strength at 4% and 65% sites of the radius were evaluated. RESULTS Trabecular BMD was normal in TS (mean Z-score = -0.2 ± 1.1, P = .5) as well as SHOX-D patients (mean Z-score = 0.5 ± 1.5, P = .3). At the proximal radius, we observed increased total bone area (Z-scores = 0.9 ± 1.5, P = .013, and 1.5 ± 1.4, P = .001, for TS and SHOX-D patients, respectively) and thin cortex (Z-scores = -0.7 ± 1.2, P = 0.013, and -2.0 ± 1.2, P < .001, respectively) in both groups. Bone strength index was normal in TS as well as SHOX-D patients (Z-scores = 0.3 ± 1.0, P = .2, and 0.1 ± 1.3, P = .8, respectively). CONCLUSIONS The similar bone geometry changes of the radius in TS and SHOX-D patients support the hypothesis that loss of 1 copy of SHOX is responsible for the radial bone phenotype associated with TS.
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Affiliation(s)
- O Soucek
- Department of Pediatrics, Second Faculty ofMedicine, Charles University in Prague and University Hospital Motol, 15006 Prague 5, Czech Republic.
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Hansen S, Brixen K, Gravholt CH. Compromised trabecular microarchitecture and lower finite element estimates of radius and tibia bone strength in adults with turner syndrome: a cross-sectional study using high-resolution-pQCT. J Bone Miner Res 2012; 27:1794-803. [PMID: 22492464 DOI: 10.1002/jbmr.1624] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Although bone mass appear ample for bone size in Turner syndrome (TS), epidemiological studies have reported an increased risk of fracture in TS. We used high-resolution peripheral quantitative computed tomography (HR-pQCT) to measure standard morphological parameters of bone geometry and microarchitecture, as well as estimated bone strength by finite element analysis (FEA) to assess bone characteristics beyond bone mineral density (BMD) that possibly contribute to the increased risk of fracture. Thirty-two TS patients (median age 35, range 20-61 years) and 32 healthy control subjects (median age 36, range 19-58 years) matched with the TS participants with respect to age and body-mass index were studied. A full region of interest (ROI) image analysis and a height-matched ROI analysis adjusting for differences in body height between groups were performed. Mean bone cross-sectional area was lower in TS patients in radius (-15%) and tibia (-13%) (both p < 0.01) whereas cortical thickness was higher in TS patients in radius (18%, p < 0.01) but not in tibia compared to controls. Cortical porosity was lower in TS patients at both sites (-32% in radius, -36% in tibia, both p < 0.0001). Trabecular integrity was compromised in TS patients with lower bone volume per tissue volume (BV/TV) (-27% in radius, -22% in tibia, both p < 0.0001), trabecular number (-27% in radius, -12% in tibia, both p < 0.05), and higher trabecular spacing (54% in radius, 23% in tibia, both p < 0.01). In the height-matched ROI analysis, differences remained significant apart from total area at both sites, cortical thickness in radius, and trabecular number in tibia. FEA estimated failure load was lower in TS patients in both radius (-11%) and tibia (-16%) (both p < 0.01) and remained significantly lower in the height-matched ROI analysis. Conclusively, TS patients had compromised trabecular microarchitecture and lower bone strength at both skeletal sites, which may partly account for the increased risk of fracture observed in these patients.
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Affiliation(s)
- Stinus Hansen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark.
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Trolle C, Hjerrild B, Cleemann L, Mortensen KH, Gravholt CH. Sex hormone replacement in Turner syndrome. Endocrine 2012; 41:200-19. [PMID: 22147393 DOI: 10.1007/s12020-011-9569-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 11/12/2011] [Indexed: 01/15/2023]
Abstract
The cardinal features of Turner syndrome (TS) are short stature, congenital abnormalities, infertility due to gonadal dysgenesis, with sex hormone insufficiency ensuing from premature ovarian failure, which is involved in lack of proper development of secondary sex characteristics and the frequent osteoporosis seen in Turner syndrome. But sex hormone insufficiency is also involved in the increased cardiovascular risk, state of physical fitness, insulin resistance, body composition, and may play a role in the increased incidence of autoimmunity. Severe morbidity and mortality affects females with Turner syndrome. Recent research emphasizes the need for proper sex hormone replacement therapy (HRT) during the entire lifespan of females with TS and new hypotheses concerning estrogen receptors, genetics and the timing of HRT offers valuable new information. In this review, we will discuss the effects of estrogen and androgen insufficiency as well as the effects of sex HRT on morbidity and mortality with special emphasis on evidence based research and areas needing further studies.
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Affiliation(s)
- Christian Trolle
- Department of Endocrinology and Internal Medicine and Medical Research Laboratories, Aarhus University Hospital, 8000 Aarhus C, Denmark
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Soucek O, Komrska V, Hlavka Z, Cinek O, Rocek M, Zemkova D, Lebl J, Sumnik Z. Boys with haemophilia have low trabecular bone mineral density and sarcopenia, but normal bone strength at the radius. Haemophilia 2011; 18:222-8. [PMID: 21752160 DOI: 10.1111/j.1365-2516.2011.02616.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although a decreased areal bone mineral density (BMD) has been reported in patients with haemophilia, data are lacking that would reflect the three-dimensional structure of the bone and the muscle-bone relationship. We aimed to assess volumetric BMD, bone geometry and muscle-bone phenotype in boys with haemophilia, and to describe the association between clinical characteristics of haemophilia and bone quality and structure. A cross-sectional study was conducted in 41 boys with haemophilia (mean age 12.4, range 6.6-19.8 years) using peripheral quantitative CT (pQCT) at the nondominant forearm. Results were transformed into Z-scores using previously published reference data. Significant differences were tested by one-sample t-test or sign test. Two-sample t-test and anova were used to compare results between subgroups of patients divided according to the severity of the disease, the fracture history and the number of joint and muscle bleedings. Boys with haemophilia had a decreased trabecular volumetric BMD (mean Z-score -0.5, P < 0.01), while their cortical volumetric BMD was increased (mean Z-score 0.4, P < 0.05). The volumetric bone mineral content and the bone geometry at the radial diaphysis were normal when adjusted for patients' shorter body height. Muscle area was decreased (mean Z-score -1.0, P < 0.001), irrespective of age. No association was observed of bone quality parameters and bone geometry with the disease severity, fracture history or number of bleedings. Bone strength measured at the diaphysis of the radius is not impaired in boys with haemophilia. The finding of the decreased trabecular bone density can be most likely attributed to their sarcopenia.
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Affiliation(s)
- O Soucek
- Department of Paediatrics, University Hospital Motol, 2nd Faculty of Medicine, Charles University In Prague, Prague, Czech Republic.
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