Clinical practice guidelines for the care of girls and women with Turner syndrome: proceedings from the 2016 Cincinnati International Turner Syndrome Meeting

Gonadal Tumors in Individuals with Turner Syndrome and Y-Chromosome Mosaicism: A Retrospective Multisite Study

STUDY OBJECTIVE

To evaluate the prevalence of germ cell tumors and the clinical monitoring practices for those who deferred prophylactic gonadectomy in a large North American cohort of individuals with Turner syndrome with Y-chromosome mosaicism (TS+Y).

METHOD

A query of the medical records at multiple North American children's hospitals was done using ICD codes related to Turner Syndrome. A retrospective chart review was conducted on those patients between ages 0 to 30 years with Y-mosaicism.

RESULTS

The data of 57 participants were analyzed. Eight (25.8%, n = 31) ≥ 13 years underwent spontaneous thelarche. One (3.2%) had spontaneous menarche. Forty-seven (82.5%) had gonadectomy at a median age of 8 years (IQR 11.0, range <1 to 19 years). Sixteen (34%) had growth hormone therapy exposure prior to gonadectomy. Fourteen (29.8%) had gonadoblastoma. Two (4.3%) had dysgerminoma. Differences in age at gonadectomy, presence of the entire Y-chromosome, and exposure to growth hormone when comparing those with vs without gonadal tumor were not statistically significant. Gonadectomy had not been performed in 10 individuals, median age 6.5 (IQR 9.0, range <1 to 14 years). There was no consistency in the plan for ultrasound and/or tumor markers for follow-up.

CONCLUSIONS

Our data shows a prevalence of 24.6% of gonadal tumors in individuals with TS +Y and a relatively low risk of malignant transformation (3.5%). Prior exposure to growth hormone was not predictive of the presence of gonadal tumor. Future cytogenetic studies are needed to better understand the factors involved in the development of gonadal tumors.

Group Support for Parents of Girls with Turner Syndrome-A Pilot Study

STUDY OBJECTIVE

Parents of girls with Turner syndrome (TS) are coping with various challenges associated with caring for a child with a genetic disorder. We aimed to explore the importance of group support for parents of girls with TS in a small pilot study.

METHODS

Group support sessions for parents of girls with TS were divided into meetings regarding psychological aspects, medical aspects, and social aspects. Questionnaires about how the families perceive TS and what obstacles they are facing were given before and after the group support through the Mentimeter application. Questionnaires were given at the end of the group sessions to assess efficacy and satisfaction.

RESULTS

Parents of 18 girls, with a median (interquartile range) age of 9 (5.5, 12) years old, participated in the group, 56% with 45X karyotype. On average 72% of the participants said that the sessions much/very much contributed, and 10% said that the sessions hardly contributed (P < .05). At the end of the sessions, parents shared that they felt more confident, less isolated, and gained more knowledge regarding TS, and a community-based sharing process was initiated. At the end of the support group, 15 (83%) versus 3 (17%) said they would like to continue the meetings of the support group (P = .0001).

CONCLUSION

A support group specifically designed for parents of girls diagnosed with TS enhanced cooperation and empathy through diminishing feelings of isolation, offering crucial information, and fostering a secure environment for sharing and support.

Growth charts of Brazilian girls with Turner syndrome without the use of GH or oxandrolone

OBJECTIVE

The development of specific growth charts for Turner Syndrome (TS) promotes adequate assessment of growth and weight gain, and earlier diagnosis of comorbidities, and may help to analyze the effectiveness of treatments to promote growth and puberty. The aim of this study was to construct a growth chart with the largest possible series of patients with a cytogenetic diagnosis of TS from a Brazilian reference center.

METHODS

This is a longitudinal study, with 259 cases of TS born between 1957 and 2014 and followed between 1975 and 2019, without the use of GH or oxandrolone. 3,160 height measurements and 2,918 wt measurements were used, with subsequent calculation of the Body Mass Index (BMI). For data analysis, the "GAMLSS" package of the "R" software was used.

RESULTS

The mean target height was 157.8 cm (standard deviation 5.2; median 160.4 cm). The mean height of patients with TS at 20 years of age was 145.6 cm (standard deviation 5.9; median 146.7 cm). Height, weight, and BMI by age graphs were developed for TS girls between 2 and 20 years.

CONCLUSION

These growth charts may be used to monitor the growth of girls with TS and to verify the effect of adjuvant treatments on promoting growth.

All-cause mortality and death by aortic dissection in women with Turner syndrome: A national clinical cohort study

BACKGROUND

Turner syndrome (TS) is a complex genetic disorder with raised mortality. Our objective was to investigate mortality and causes of death in TS.

METHODS

A matched retrospective observational study of women with TS recruited from the Turner centers in Sweden were conducted. A total of 472 women with TS, ≥16 years old with a cytogenetically verified diagnosis and 2357 controls, matched for birthyear and sex, were examined and followed since 1995 for up to 26 years. Survival analyses were performed with Cox proportional hazard models. Kaplan-Meier curves were generated. Cumulative incidence rates were evaluated by competing risks analysis, using cumulative incidence function.

RESULTS

During a mean follow-up of 17 years, 35 (7.4%) women with TS and 70 (3.0%) controls died. All-cause mortality was elevated in TS, hazard ratio (HR) 2.90 (95% CI 1.92-4.37), mainly due to circulatory diseases and notably aortic dissection, with HR of 9.11 (95% CI 4.54-18.25) and 21.79 (95% CI 4.62-102.82), respectively. Aortic dissection was the single largest cause of death in TS, accounting for 23% (8/35) of total deaths. Death by cancer or external causes were not raised in TS. In individuals below 45 years of age death, aortic dissections were greatly increased compared to controls, HR 55.59 (95% CI 2.33-1325.69). From the ages 46 to 80 years a notably higher risk of dying by heart diseases, aortic dissection excluded, was shown in TS compared to controls HR, 7.7 (2.65-22.36). The median survival time was 8 years shorter in TS compared to controls.

CONCLUSIONS

The increased mortality in TS was mainly driven by aortic dissections in the young and by heart diseases in the older. Healthcare professionals should prioritize detection and monitoring, with emphasis on cardiovascular diseases.

The transcriptomic landscape of monosomy X (45,X) during early human fetal and placental development

Monosomy X (45,X) is associated with Turner syndrome and pregnancy loss in humans, but the underlying mechanisms remain unclear. We therefore undertook an exploratory study of the transcriptomic landscape of clinically relevant human fetal 45,X tissues (including pancreas, liver, kidney, skin, placenta) with matched 46,XX and 46,XY control samples between 11 and 15 weeks post conception (n = 78). Although most pseudoautosomal region 1 (PAR1) genes are lower in monosomy X tissues, we also found reduced expression of several key genes escaping X inactivation (e.g., KDM5C and KDM6A), several ancestral X-Y gene pairs, and potentially clinically important transcripts such as genes implicated in ascending aortic aneurysm. In contrast, higher expression of an autosomal, long non-coding RNA (OVCH1-AS1) is seen in all 45,X tissues. In the placenta, lower expression of CSF2RA is demonstrated, likely contributing to immune dysregulation. Taken together, these findings provide insights into the biological consequences of a single X chromosome during early human development and potential insights in genetic mechanisms in Turner syndrome.

Associations of Karyotype and Age at Diagnosis with Physical Features and Comorbidities in Turner Syndrome: A Single-Site Experience

Aim

Turner syndrome (TS) is one of the most common genetic diseases in females, with typical physical features and comorbidities. Karyotype-phenotype associations and clinical significance of childhood versus adolescent/adulthood diagnosis are conflicting.

Purpose

Determining the role of certain TS karyotypes and early (<12 years of age) vs late (≥12 years) diagnosis in TS-specific phenotype and comorbidity penetrance.

Patients and Methods

Retrospective analysis of baseline characteristics and 45 TS-specific features and comorbidities of 75 TS patients were diagnosed between 2009 and 2019 and followed-up until 2023 in our tertiary care center.

Results

Thirteen different karyotypes were detected: 45,X,inv(10), 45,X,inv(9)(15), 45,X, 46,X,i(Xq), 46,X,del(Xp), 46,XX,del(X)q21, 45,X/46,X,del(X), 45,X/46,X,+mar, 45,X/46,X,rX, 45,X/46,XX, 45,X/46,XY, 45,X/47,XXX, 46,X,i(Xq)/47,XX,i(Xq). The classic karyotype with 45X monosomy showed an increased risk for hypertrichosis (28.6% vs 7.5%, OR 4.93, 95% CI [1.23-19.73]), pterygium colli (34% vs 12%, OR 3.65, 95% CI [1.13-11.75]) and short stature (91% vs 75%, OR 3.56 [0.89-14.17]. Mosaic karyotypes had a smaller risk of pterygium colli (OR 0.28 [0.073-1.092]) and short stature (OR 0.29 [0.086-1.026]. 45X/46XX mosaicism was associated with an increased risk of hypertension (33% vs 6%, OR 7.75 [1.39-43.08]), and the presence of the iso (Xq) chromosome increased the risk of celiac disease (28% vs 3%, OR 13.2 [1.52-114.52]). 44/75 (58.6%) of the cohort were diagnosed at <12 years of age. In the <12-year-old diagnosis group, facial dysmorphism and low hairline, (OR 3.30, [1.26-8.65]), low-set ears (OR 2.51 [0.98-6.46]), and breasts abnormalities (OR 4.71 [1.72-12.83]), short stature (OR 4.09 [1.13-14.82]) and GH therapy (OR 4.93 [1.31-16.01]) occurred more frequently. If diagnosed <12 years, patients had a decreased risk of hepatosplenomegaly (OR 0.10 [0.02-0.50]) and hypertension (OR 0.097 [0.01-0.85]).

Conclusion

TS patients should be handled as a heterogenous group, as they seem to differ in the penetrance of phenotypical features of the disease and the risk of comorbidities depending on karyotype and age at diagnosis.

Exploring the experiences of adult patients with turner syndrome at a multidisciplinary clinic

OBJECTIVE

To explore the experiences of adults with Turner syndrome 1) attending a multidisciplinary Turner syndrome clinic regarding reproductive and general health; and 2) interacting with a multidisciplinary team for the management of their Turner syndrome.

STUDY DESIGN

In this descriptive, qualitative study, 21 adults with Turner syndrome who attend a multidisciplinary Turner syndrome clinic participated in semi-structured interviews. An inductive approach was used to code data and determine themes.

RESULTS

Five themes were identified. 1) Differing feelings toward fertility status. Experiences with fertility differed widely, based on timing and communication of diagnosis, and feelings toward having children. 2) Adaptability and overcoming challenges. Participants sought ways to adapt to living with Turner syndrome. 3) Engagement in one's own care. Participants were engaged in their care and sought support in learning about their condition, especially around reproductive health. 4) Desire for comprehensive healthcare. Participants felt the multidisciplinary Turner syndrome clinic provided knowledgeable, convenient, and comprehensive care. 5) Barriers to accessing healthcare. Participants identified challenges both in accessing healthcare providers with expertise in Turner syndrome and in navigating the financial impact of Turner syndrome.

CONCLUSION

Infertility had differing impacts on adults with Turner syndrome. Participants were satisfied with the multidisciplinary care model. Our findings highlight the importance of multidisciplinary care for optimizing the experience of adults with Turner syndrome.

Elevated levels of neutrophils with a pro-inflammatory profile in Turner syndrome across karyotypes

Turner syndrome (TS) presents with multiple karyotypes, including 45,X monosomy and variants such as isochromosomes and mosaicism, and is characterized by several co-morbidities, including metabolic conditions and autoimmunity. Here, we investigated the genomic landscapes across a range of karyotypes. We show that TS have a common autosomal methylome and transcriptome, despite distinct karyotypic variations. All TS individuals lacked the X chromosome p-arm, and XIST expression from the q-arm did not affect the autosomal transcriptome or methylome, highlighting the critical role of the missing p-arm with its pseudoautosomal region 1. Furthermore, we show increased levels of neutrophils and increased neutrophil activation. The increase in neutrophils was linked to TS clinical traits and to increased expression of the X-Y homologous gene TBL1X, suggesting a genetic basis, which may lead to neutrophil-driven inflammatory stress in TS. Identifying TS individuals with increased neutrophil activation could potentially mitigate the progression towards more severe metabolic issues.

Current practices in fertility-based counseling among individuals with Turner syndrome: a retrospective study

STUDY OBJECTIVE

To evaluate current practices and examine patient and provider characteristics associated with delivery of fertility-based counseling and pursuit of oocyte cryopreservation or autologous in vitro fertilization among individuals with Turner syndrome (TS) at a large academic institution.

METHODS

A retrospective study was conducted between January 2010 and December 2020, involving phenotypically female individuals aged 0-26 years with TS.

RESULTS

Of 108 included individuals with TS, 65 (60.19%) were classified as monosomy X, and 43 (39.81%) were classified as having TS with another karyotype. Individuals with monosomy X were more likely to have cardiac anomalies, hypertension, and low bone density compared to individuals with TS with other karyotypes. Rates of other comorbidities were similar between groups. Thirty patients (27.78%) received fertility and/or fertility preservation (FP) counseling, of which 6 (5.56%) pursued autologous assisted reproduction technology (ART). A multidisciplinary group of providers offered counseling. Individuals with other TS karyotypes were more likely to receive counseling compared to individuals with monosomy X (43.59% vs. 22.03%, p=0.027). Counseling was significantly associated with pursuing ART (20.00% vs. 0%, p<0.001). Other factors, such as race, ethnicity, and cardiac anomalies, were not associated with the receipt of counseling.

CONCLUSIONS

Approximately one-third of individuals with TS receive fertility and/or FP counseling, and only few pursued controlled ovarian hyperstimulation (COH). Our large cohort study underscores the need for standardized, system-wide measures to deliver fertility counseling to individuals with TS, including the development of a dedicated multidisciplinary program. Further investigations are necessary to evaluate the effectiveness of proficiency in delivering FP counseling to individuals with TS.

Comparison of growth hormone therapy response according to the presence of growth hormone deficiency in children born small for gestational age with short stature in Korea: a retrospective cohort study

BACKGROUND

This study aimed to compare the response to growth hormone (GH) therapy according to the presence of GH deficiency (GHD) in short-stature children born small for gestational age (SGA) in Korea and to present appropriate GH dose criteria.

METHODS

We evaluated 27 children born SGA with short stature and GHD (GHD group) and 23 without GHD (non-GHD group) registered in the LG Growth Study. Growth responses and changes in GH dose over a 2-year GH therapy period were compared, and the factors affecting growth response were investigated.

RESULTS

The standard deviation scores (SDSs) for baseline weight and body mass index (BMI) were significantly lower in boys without GHD than in boys with GHD. The SDS for insulin-like growth factor-1 (IGF-1) was lower among boys without GHD than among boys with GHD, while the SDS for insulin-like growth factor-binding protein-3 (IGFBP-3) was higher among girls without GHD than among girls with GHD; however, there was no significant difference when comparing all children with GHD to those without GHD. Regardless of the presence of GHD, the difference between chronological age and bone age decreased annually. Notably, there was significantly rapid bone age progression among patients without GHD. The findings showed differences in GH dose according to GHD starting from the 2nd year of therapy, with the non-GHD group receiving a significantly higher dose. Regarding the factors affecting growth response, younger age and bone age, higher height SDS, BMI SDS and MPH SDS were related to higher growth response (Δheight SDS and Δgrowth velocity), but there was no statistically significant correlation.

CONCLUSION

GHD is rare among children born SGA. Nonetheless, if there are any signs of decreased growth velocity or hypopituitarism, the presence of GHD should be assessed before GH therapy, and personalized therapy based on the results is required.

Improvement of Bone Metabolism in Prepubertal Girls with Turner Syndrome Following Long-term Pegylated Growth Hormone Treatment

The study aims to assess the improvement in bone metabolism in prepubertal girls with Turner Syndrome (TS) after long-term polyethylene glycol recombinant human Growth Hormone (PEG-rhGH) treatment. A 12-month longitudinal prospective study was conducted with 28 prepubertal girls diagnosed with TS. Participants were divided into two groups: 18 received PEG-rhGH therapy (0.1-0.25 mg/kg/week) and 10 did not. Anthropometric measurements, bone turnover markers (BTMs), and serum levels of IGF-1, calcium, and phosphate were collected at baseline and after 12 months. BTMs included bone alkaline phosphatase (BAP), Type I collagen propeptide (CICP), Type I collagen telopeptide (CTX), and fibroblast growth factor 23 (FGF23). After 12 months of PEG-rhGH therapy, the treatment group showed significant increases in growth velocity (GV) and height standard deviation scores (HtSDS). Serum IGF-1 levels increased rapidly within one month and remained elevated. BTMs indicated enhanced bone formation, significantly increasing BAP and CICP, while CTX levels remained low. FGF23 levels initially rose slightly but declined below baseline by 12 months. Elevated blood phosphate levels were observed. PEG-rhGH therapy in children with TS significantly improves linear growth and enhances bone formation markers, benefiting bone metabolism.

Decoding Hearts: Genetic Insights and Clinical Strategies in Congenital Heart Disease

Structural congenital heart disease (CHD) represents a heterogeneous group of cardiac anomalies of variable embryologic and molecular origins. A basic understanding of the genetics implicated in nonsyndromic (isolated) and syndromic structural CHD can better inform management decisions and family counseling. When a fetus or neonate develops CHD as a result of a genetic cause, it can be due to a mutation or a monogenic, oligogenic, or polygenic pathogenic variant. In this review, we summarize basic cardiac embryology in the context of genetic signaling pathways and proteins that are commonly implicated in syndromic and nonsyndromic structural CHD. We also provide an overview of the basic genetic evaluation in infants with common syndromic structural CHD.

Elective Aortic Surgery for Prevention of Aortic Dissection in Turner Syndrome: The Potential Impact of Updated European Society of Cardiology and International Turner Syndrome Consensus Group Guidelines on Referrals to the Heart Team

OBJECTIVE

The risk of aortic dissection is increased in Turner Syndrome (TS). Aortic dilation is thought to contribute to this risk and may be managed with elective aortic surgery. New TS guidance has lowered the aortic size thresholds for consideration of aortic surgery. We investigated the impact of new guidance on potential heart team referrals in a UK cohort of TS individuals.

METHODS

A cross-sectional study of 156 individuals with TS was performed. Up to date transthoracic echocardiography or cardiac MRI derived aortic dimensions, anthropometric data and the presence of aortic dissection risk factors were analysed.

RESULTS

Twenty-one individuals (13%) met updated guideline criteria for consideration of aortic surgery, 15 more than met 2016 TS guideline criteria. Use of aortic size index (ASI) and aortic height index (AHI) together identified additional individuals meeting criteria for surgical consideration compared with the use of ASI or AHI alone. Z-score identified no additional individuals for surgical consideration, nor did it reclassify any individuals into moderate or severe aortic dilation groups. Twelve of 13 individuals with moderate aortic dilation met criteria for surgical consideration due to the presence of additional risk factors for aortic dissection. There was no positive correlation between height or body surface area and ascending aorta diameter in this cohort.

CONCLUSIONS

New TS guidelines are likely to significantly increase the number of individuals with TS who might be considered for elective aortic surgery. Centres caring for individuals with TS should re-evaluate their TS cohorts for aortic dissection risk considering these new guidelines.

Karyotype and phenotype association in Turner syndrome with non-mosaic X chromosome structural rearrangements: Systematic review

Turner syndrome is a chromosomal disorder, characterized by the partial or total deletion of one X chromosome, resulting in various karyotypes that presumably lead to different phenotypes. However, most studies find it difficult to predict phenotypes from karyotypes due to the presence of mosaicism. The purpose of this study is to clarify the relationship between karyotype and phenotype in Turner syndrome with non-mosaic X chromosome structural rearrangements. A systematic literature search was conducted using Medline and Embase classics plus Embase between 1947 and September 2023. A total of 487 Turner women with non-mosaic X chromosome structural rearrangements were included from the 69 studies. The prevalence of short stature was 72.4% in Turner syndrome with non-mosaic X chromosome structural rearrangements, 80.1% in the short arm deletion group (del (Xp)), 75% in the del(X)(p22.3) group, 65.8% in the del(X)(p21) and del(X)(p22) group, and 37.5% (20%-66.7%) in the long arm deletion group (del(Xq)). The prevalence of ovarian dysfunction was 78.8% in Turner syndrome with non-mosaic X chromosome structural rearrangements, 72.5% in the del (Xp) group, 27.6% in the del (X)(p22.3) group, 33.3% in the del (X)(p21) and del(X)(p22) group, and 94.6% in the del (Xq) group. The recognition of X chromosome breakpoints is useful in the management of Turner syndrome complications, since some phenotypes are unique depending on the deletion region. Ovarian dysfunction is significantly related to karyotype, so the identification of karyotypes in Turner syndrome is important for managing ovarian dysfunction and predicting future fertility.

Development of Neuroblastoma During Growth Hormone Therapy for Short Stature in a Girl With Mosaic Turner Syndrome

We report the case of a girl with mosaic Turner syndrome who developed abdominal neuroblastoma during growth hormone (GH) therapy for short stature. The patient underwent chemotherapy for the unresectable tumor but died at the age of 10 years due to multiple metastases, five years and 10 months after the diagnosis of neuroblastoma. Although the risk of neuroblastoma does not increase in patients with Turner syndrome, the need for pre-treatment imaging studies for tumor screening remains controversial. However, our experience with this patient highlights the potential value of performing imaging studies both before and during GH treatment.

Oral Hormone Replacement Therapy and Uterine Volume in Korean Adolescents with Turner Syndrome: A Retrospective Case-Control Study

STUDY OBJECTIVE

We aimed to identify critical factors for uterine development by comparing uterine volume (UV) among patients with Turner syndrome (TS) who underwent pubertal induction (PI), patients with TS who had natural menarche (NM), and patients in a non-TS control group.

METHODS

This retrospective case-control study included patients with TS who had undergone PI with oral estrogen in a PI group (n = 31) and an NM group (n = 7). The control group included patients without TS with spontaneous puberty who underwent pelvic ultrasound at 16 years of age. For TS patients, both the UV from the first ultrasound performed at age 16 or older (1st-UV) and the UV from the most recent final ultrasound (final-UV) were obtained.

RESULTS

The 1st-UV was larger for patients in the NM group than those in the PI group (P < .001), but did not differ significantly between the NM and control groups (P = .375). The final-UV of the PI group was larger than their 1st-UV (P < .001), but still smaller than the NM group (P = .021). Hormone replacement therapy (HRT) duration and 1st-UV of PI group were positively correlated (P = .048). There were no variables that were significantly correlated with final-UV of PI group.

CONCLUSION

Patients with TS who experienced NM showed normal uterine development, but TS patients who underwent PI showed significantly smaller, undeveloped UV. While HRT duration and UV are positively correlated at the beginning of HRT, it is unclear what determines the final UV; however, late PI initiation and use of oral estrogen probably contributed to the lack of UV development.

Genetics in Reproductive Medicine

Thanks to advances in technology, genetic testing is now available to explore the causes of infertility and to assess the risk of a given couple passing on a genetic disorder to their offspring. This allows at-risk couples to make an informed decision when opting for assisted reproduction and allows professionals to offer pre-implantation diagnosis when appropriate. Genetic screening of an infertile couple has thus become standard practice for an appropriate diagnosis, treatment, and prognostic assessment. This review aims to highlight the conditions under which genetic screening plays a role in improving reproductive outcomes for infertile couples.

Bone mineral density: Comparison between women under hormone replacement therapy with Turner syndrome or idiopathic premature ovarian insufficiency

CONTEXT

Turner syndrome (TS) is characterized by short stature and premature ovarian insufficiency (POI). The main long-term complication of POI is osteoporosis, which can be prevented by hormone replacement therapy (HRT).

OBJECTIVE

The objective of our study was to compare initial bone mineral density (BMD) and progression between TS and idiopathic POI patients under HRT.

METHODS

A single-center retrospective study was conducted between 1998 and 2018. All women had undergone at least two bone densitometry assessments at least 2 years apart.

RESULTS

Sixty-eight TS patients and 67 idiopathic POI patients were included. Mean age at initial assessment was 27 years (IQR, 21-35.5 years) in TS patients and 31.5 years (IQR, 23-37 years) in idiopathic POI patients (P=0.1). Lumbar and femoral neck BMD were lower in the TS group than in the idiopathic POI group (respectively 0.89g/cm2 versus 0.95g/cm2, P=0.03; 0.70g/cm2 versus 0.77g/cm2, P<0.0001). Mosaic karyotype was associated with better BMD in TS patients while history of growth hormone treatment had no impact on BMD. Over time, a significant gain in vertebral BMD was observed in TS patients versus a loss of BMD in idiopathic POI patients (P=0.0009).

CONCLUSION

TS patients had a lower BMD at baseline than idiopathic POI patients, at both spinal and femoral levels. Over time, on HRT, a significant gain in vertebral BMD was observed in patients with TS, compared with a loss of BMD in patients with idiopathic POI. We hypothesized that earlier initiation and longer duration of HRT played an important role in this finding. Long-term prospective follow-up to assess the incidence of fractures in TS would be useful.

Genetic disorders in maternal medicine

The role of genetic testing within maternal medicine is expanding. Advancing technology and the increasing availability of genetic testing have seen more patients receiving a genetic diagnosis than ever before. Improved healthcare and understanding of these rare diseases means that many patients are living well into their reproductive years and starting families. Individual diseases are considered by their patterns of inheritance i.e. autosomal recessive, autosomal dominant and chromosomal diseases. This chapter specifically addresses the following examples and outlines an approach to pre-conceptual and pregnancy management; autosomal recessive (cystic fibrosis, phenylketonuria), autosomal dominant (osteogenesis imperfecta, vascular Ehlers-Danlos syndrome) and chromosomal (Turner syndrome). For many rare and ultrarare genetic diseases, there may be no clear guidelines or consensus on the correct management in pregnancy. This chapter seeks to provide a framework for the clinician to use to address the unique needs and risk profile of these patients in pregnancy and pre-conceptually and plan accordingly. The role of pharmacogenetics in maternal medicine, the future of education in genetics for patients and clinicians and the important role of genetic counselling are all considered in this chapter. This overview highlights the important role of genetics in maternal medicine and how this can inform management and planning for the safe care of mother and baby.

Cardiovascular Diseases in Public Health: Chromosomal Abnormalities in Congenital Heart Disease Causing Sudden Cardiac Death in Children

Chromosomal abnormalities (CAs) are changes in the number or structure of chromosomes, manifested as alterations in the total number of chromosomes or as structural abnormalities involving the loss, duplication, or rearrangement of chromosomal segments. CAs can be inherited or can occur spontaneously, leading to congenital malformations and genetic diseases. CAs associated with cardiovascular diseases cause structural or functional alterations of the heart, affecting the cardiac chambers, valves, coronary arteries, aorta, and cardiac conduction, thus increasing the likelihood of arrhythmias, cardiac arrest, and sudden cardiac death (SCD). An early diagnosis and the adequate management of chromosomal abnormalities associated with cardiovascular diseases are essential to prevent SCD, which is a serious public health problem today. In our review, we analyzed the structural and functional CAs responsible for congenital heart disease (CHD) that increase the risk of SCD and analyzed the prevention strategies to be implemented to reduce SCD.

Selecting optimal progestational agents either alone or in combination in common pediatric endocrine settings: challenges of unmet needs

Progesterone is a natural hormone, mainly produced by the corpus luteum, with the foremost endocrine function on the secretory glands of the endometrium. Since being isolated, both natural and synthetic forms have been produced and are utilized for several purposes, including regulating the menstrual cycle and preventing endometrial hyperplasia. Specifically, the use of progestational agents is essential in the treatment of many common endocrine conditions, including polycystic ovary syndrome, congenital adrenal hyperplasia Turner syndrome and functional hypothalamic amenorrhea. Although these agents are essential for disease management, literature that focuses on the benefits of specific progestins as well as the effects on glucocorticoid receptors (GR), mineralocorticoid receptors (MR), and androgenic receptors (AR) is limited. In this review, we provide a disease specific summary of the available literature and highlight where more information is needed.

A single-center's uric acid profile in girls with Turner syndrome

Background

Metabolic disorders are common in individuals with Turner syndrome (TS). Hyperuricemia is associated with metabolic syndrome. This study investigated the serum uric acid (SUA) profile in patients with TS.

Methods

A retrospective observational study was conducted with 145 patients with TS. A total of 72 normal girls were in the control group from 2015 to 2024: 86 TS patients were treated with growth hormone (GH), 80 with stanozolol, and 52 with estrogen.

Results

Hyperuricemia was present in 33.1% (47/145) of patients with untreated TS and in 16.67% (12/72) of the controls (P < 0.001). Multivariable linear regression analysis showed that BMISDS, fasting serum glucose, and eGFR explained 34.4% (model R 2 = 0.344) of the total variation in SUA in the untreated TS group. SUA and SUASDS (SUA standard deviation score) levels generally showed a slow rising tendency with age. SUA increased significantly in the first year of stanozolol initiation (P = 0.032), while adding estrogen and stanozolol improved the lipid profile during the whole assessment period.

Conclusion

Girls with TS showed a slow rising tendency in SUA and SUASDS with age and had higher SUA and SUASDS levels and incidence of hyperuricemia compared to their healthy female peers. The independent risk factors for hyperuricemia in pediatric patients with TS were BMISDS, HOMA-IR, glucose, and eGFR. The incidence of hyperuricemia increased in the first year of stanozolol treatment.

The Unique Challenge of Coronary Artery Disease in Adult Patients with Congenital Heart Disease

Advances in medical and surgical interventions have resulted in a steady increase in the number of patients with congenital heart disease (CHD) reaching adult age. Unfortunately, this ever-growing population faces an added challenge: an increased risk of acquiring coronary artery disease. This review provides insight into the complex interactions between coronary artery disease and CHD in adults. We describe the peculiar features of cardiac anatomy in these patients, the possible role cardiac sequelae may play in an increased risk of myocardial ischemia, and the diagnostic challenges in this patient group. Furthermore, this review outlines the risk factors and potential mechanisms of accelerated atherosclerosis in adults with CHD by pointing out areas where current knowledge is incomplete and highlighting areas for further research. The review concludes by examining potential management strategies for this particular population, emphasizing the necessity for a multidisciplinary approach. Understanding the unique coronary risks that adults with CHD experience can enhance patient care and improve long-term results.

Lifelong medical challenges and immunogenetics of Turner syndrome

Turner syndrome (TS) is a female phenotypic condition characterized by one or more typical clinical features and the partial or complete absence of a second X chromosome as determined by karyotype analysis. TS, among the most common chromosomal abnormalities, has an estimated prevalence of approximately 1 in 2,500 live-born females, with ethnic and racial differences. TS encompasses a wide array of medical challenges, including cardiovascular, endocrine, autoimmune, and mental health issues, as well as a heightened cancer risk. The somatic stigmata of TS are thought to arise from haploinsufficiency of the X chromosomes. This review explores the lifelong medical challenges and immunogenetics of individuals with TS and aimed to investigate strategies for preventing and managing TS while considering the implications of immunogenetics.

Multimodality Evaluation of Turner Syndrome With Right Ventricular Dilation and Partial Anomalous Pulmonary Venous Return

Turner syndrome is a rare chromosomal abnormality in women that is caused by a partial or complete loss of one X chromosome and is often associated with a spectrum of congenital cardiac abnormalities, including cardiac shunts.  A 27-year-old woman with Turner syndrome was also found to have right ventricular dilation, partial anomalous pulmonary venous return, and possible atrial septal defect. She was scheduled for elective surgical repair. However, a preoperative review of diagnostic imaging raised the specter of Eisenmenger syndrome, a highly morbid condition defined by secondary, severe pulmonary hypertension where shunt correction may potentiate acute hemodynamic collapse. Multimodality imaging and invasive hemodynamics were used to comprehensively evaluate shunt physiology and guide surgical correction.

Society for endocrinology guideline for understanding, diagnosing and treating female hypogonadism

Female hypogonadism (FH) is a relatively common endocrine disorder in women of premenopausal age, but there are significant uncertainties and wide variation in its management. Most current guidelines are monospecialty and only address premature ovarian insufficiency (POI); some allude to management in very brief and general terms, and most rely upon the extrapolation of evidence from the studies relating to physiological estrogen deficiency in postmenopausal women. The Society for Endocrinology commissioned new guidance to provide all care providers with a multidisciplinary perspective on managing patients with all forms of FH. It has been compiled using expertise from Endocrinology, Primary Care, Gynaecology and Reproductive Health practices, with contributions from expert patients and a patient support group, to help clinicians best manage FH resulting from both POI and hypothalamo-pituitary disorders, whether organic or functional.

Puberty progression in girls with Turner syndrome after ovarian tissue cryopreservation

OBJECTIVE

To study the impact of unilateral ovariectomy for ovarian tissue cryopreservation (OTC) on the function of the remaining ovary in girls with Turner syndrome.

DESIGN

A prospective cohort study as a follow-up of OTC in a research setting (the TurnerFertility trial, NCT03381300).

SETTING

University Hospital.

PATIENT(S)

A total of 28 girls with Turner syndrome with follicles in their cryopreserved ovarian cortex tissue, aged 5-19 years. Of the 28 girls, 21 had a 45,X/46,XX mosaic karyotype; 5 had structural aberrations of the X chromosome; 1 had a 45,X monosomy; and 1 had a 45,X/47,XXX karyotype.

INTERVENTION(S)

Girls were monitored annually after OTC for pubertal development and levels of antimüllerian hormone (AMH), follicle-stimulating hormone, luteinizing hormone, estradiol, and inhibin B.

MAIN OUTCOME MEASURE(S)

Thelarche, menarche, and onset of premature ovarian insufficiency.

RESULT(S)

The girls were monitored for a median duration of 3.4 years (maximum 6.6 years). The pubertal development of five prepubertal girls is still unknown; all were aged <10 years and had low gonadotropin and estradiol levels at the end of the follow-up. Seven of the eight girls of approximately pubertal age (10-12 years) experienced spontaneous thelarche, although one received medication to induce puberty. Eleven of the 14 girls between the ages of 14-17 years experienced spontaneous menarche; three other girls with thelarche still had ongoing puberty at the end of follow-up with normal gonadotropins and AMH levels above the detection limit. Approximately 6-12 months after OTC, a decline in AMH concentration was observed in 57% (16/28) of girls, followed by an increase in AMH concentration in the following years. Six of the total 28 girls started hormone replacement therapy because of symptoms of premature ovarian insufficiency, and all had AMH levels <0.50 μg/L before OTC.

CONCLUSION(S)

Pubertal development progressed after unilateral ovariectomy for OTC in most girls with Turner syndrome. Hormone replacement therapy was required within a few years for girls with unfavorable parameters before OTC, such as AMH levels <0.50 μg/L. Decisions regarding OTC should be personalized, considering the girl's preferences and specific characteristics.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03381300-Preservation of ovarian cortex tissue in girls with Turner syndrome-Full Text View-ClinicalTrials.gov. Registered on: December 21, 2017. The first patient was recruited on January 1, 2018.

Growth During Pubertal Induction in Girls With Turner Syndrome: A Retrospective Cohort Analysis

CONTEXT

Patients with Turner syndrome (TS) often present with short stature and ovarian insufficiency. The optimal method of pubertal induction to maximize adult height (AH) is unknown.

OBJECTIVE

To identify variables related to pubertal induction that are associated with growth and AH.

METHODS

This retrospective cohort analysis of patients attending a specialized TS clinic at a quaternary children's hospital included patients with TS (n = 107) who attended the clinic between 2015 and 2021. Among them, 51 received estradiol for pubertal induction. Main outcome measures were changes in height SD score (ΔHeightSDS) during pubertal induction and AH. Age at pubertal induction, bone age delay, mid-parental height (MPH), growth hormone treatment, and karyotype were assessed as predictors of AH and ΔHeightSDS. Associations between karyotype and comorbidities were also assessed.

RESULTS

AH was predicted by MPH (0.8 cm/cm, P = .0001) and bone age delay (-1.84 cm/year, P = .006). ΔHeightSDS was predicted by growth hormone dose (0.09 SDS/mg/m2/week; P = .017), bone age delay (-1.37 SDS/year; P = .003), and age at pubertal induction (0.44 SDS/year; P = .001). There was an interaction between bone age delay and pubertal induction age (P = .013), with the combination of younger age at pubertal induction and a less-delayed bone age associated with a lower ΔHeightSDS. Karyotype did not influence AH or ΔHeightSDS but did affect rates of other comorbidities.

CONCLUSION

Decisions around timing of pubertal induction in patients with TS should be tailored to the individual. The current approach to estrogen supplementation needs to be refined in order to facilitate pubertal induction in a physiological manner without compromising height.

Epigenomic newborn screening for conditions with intellectual disability and autistic features in Australian newborns

This study describes a protocol to assess a novel workflow called Epi-Genomic Newborn Screening (EpiGNs) on 100,000 infants from the state of Victoria, Australia. The workflow uses a first-tier screening approach called methylation-specific quantitative melt analysis (MS-QMA), followed by second and third tier testing including targeted methylation and copy number variation analyzes with droplet digital PCR, EpiTYPER system and low-coverage whole genome sequencing. EpiGNs utilizes only two 3.2 mm newborn blood spot punches to screen for genetic conditions, including fragile X syndrome, Prader-Willi syndrome, Angelman syndrome, Dup15q syndrome and sex chromosome aneuploidies. The program aims to: identify clinically actionable methylation screening thresholds for the first-tier screen and estimate prevalence for the conditions screened.

A Case of Idiopathic Central Diabetes Insipidus and a Mosaic Form of Turner Syndrome

Central diabetes insipidus is a clinical syndrome caused by the loss of function of vasopressinergic neurons in the hypothalamus, which results in impaired secretion of arginine vasopressin (AVP). AVP deficiency leads to the inability to concentrate urine, resulting in hypotonic polyuria and polydipsia. The condition is most often acquired, but in some cases, the etiology remains unknown, in which the disease is classified as idiopathic. Turner syndrome is the most common sex chromosome abnormality in women, caused by complete or partial absence of one of the two X chromosomes. In some cases of Turner syndrome, an abnormal cell division occurs during the early stages of the fetal development, resulting in mosaicism: some cells in the body possess two complete copies of the X chromosome, while others have only one. The coexistence of Turner syndrome and diabetes insipidus is extremely rare but should nevertheless be sought in all patients through focused clinical thinking and testing, as both conditions have long-term health consequences and should be promptly diagnosed and treated. We report a clinical case of a 22-year-old female patient, diagnosed with idiopathic central diabetes insipidus and a mosaic form of Turner syndrome, presenting with polyuria and polydipsia. The performed water deprivation and desmopressin tests proved a central form of diabetes insipidus. The imaging studies that were conducted, an MRI of the hypothalamic-pituitary region in particular, revealed the existence of a "dark" type microadenoma with discrete compression of the infundibulum. The patient was started on vasopressin replacement treatment with a good therapeutic effect. In the follow-up imaging studies, the structure of the pituitary gland showed no dynamics. There are only a few cases of simultaneous development of central diabetes insipidus and Turner syndrome that have been described in the literature. Further research is needed in order to discover the connection between the pathogenesis of the development of antidiuretic hormone deficiency and Turner syndrome.

Cardiovascular Manifestations of Turner Syndrome: Phenotypic Differences Between Karyotype Subtypes

Turner syndrome (TS) is a genetic disorder presenting in phenotypic females with total or partial monosomy of the X chromosome. Cardiovascular abnormalities are common, including congenital heart defects (CHD) and aortic dilation. Although mosaic TS is suspected to have less severe phenotype as compared to non-mosaic TS, differences in cardiovascular manifestations between karyotypes are not well studied. This is a single-center retrospective cohort study including patients with TS seen from 2000 to 2022. Demographic data, chromosomal analysis, and imaging were reviewed. Karyotypes were categorized as monosomy X (45X), 45X mosaicism, isochromosome Xq, partial X deletions, ring X (r(X)), TS with Y material, and others. Prevalence of CHD and aortic dilation were compared between monosomy X and other subtypes using Pearson's chi-square test and Welch two-sample t-test. We included 182 TS patients with median age 18 (range 4-33) years. CHD was more common in monosomy X as compared with others (61.4% vs. 26.8%, p < 0.001), including bicuspid aortic valve (44.3% vs. 16.1%, p < 0.001), partial anomalous pulmonary venous return (12.9% vs. 2.7%, p = 0.023), persistent left superior vena cava (12.9% vs. 1.8%, p = 0.008), and coarctation of the aorta (20.0% vs. 4.5%, p = 0.003). Cardiac surgery (24.3% vs. 8.9%, p = 0.017) was more prevalent in the monosomy X group. There was no statistically significant difference for presence of aortic dilation (7.1% vs 1.8%, p = 0.187). Although CHD and need for cardiac surgery are more common in TS with monosomy X as compared to others, all TS subtypes may have similar risk of developing aortic dilation. All TS patients should have similar cardiovascular surveillance testing to monitor for aortic dilation.

Clinical dilemmas in ovarian tissue cryopreservation

Ovarian tissue cryopreservation (OTC) is increasingly offered globally as a fertility preservation strategy for both postpubertal women and prepubertal girls, with subsequent reimplantation of cryopreserved ovarian cortex resulting in a rapidly growing number of live births. There remains very limited evidence of efficacy from tissue stored when the patient was prepubertal or from conditions affecting the ovary directly, e.g., Turner syndrome. Although OTC is becoming a more established practice, several clinical dilemmas remain from a practical and ethical standpoint. This review discusses the challenges regarding optimal patient selection for the procedure, the use of OTC in patients with a poor prognosis, the potential of reimplantation of tissue contaminated with malignant cells, and the role of OTC in those with an intrinsic ovarian disorder.

Maternal cardiovascular morbidity and mortality associated with pregnancy in individuals with Turner syndrome: a committee opinion

In individuals with Turner syndrome, the risk of death from aortic dissection or rupture during pregnancy may be as high as 1%, and it is unclear whether this risk persists during the postpartum period owing to pregnancy-related aortic changes. Turner syndrome is a relative contraindication for pregnancy; however, it is an absolute contraindication for pregnancy in a patient with an aortic size index of >2.5 cm/m2 or an aortic size index of ≥2.0 cm/m2 with a documented cardiac anomaly or other risk factors. This document replaces the 2012 document of the same name.

Response of children with Turner syndrome with different types of karyotype abnormalities to growth hormone treatment

PURPOSE

Short stature is the main characteristic of Turner syndrome (TS) patients and growth hormone (GH) therapy has been essential for achieving the final adult height (Ht). In the present study, the response of TS patients with different types of karyotype abnormalities to GH therapy was analyzed.

METHODS

The clinical parameters of 194 TS patients registered in the LG Growth Study were retrospectively reviewed. Data for 4 groups of subjects were obtained as follows: monosomy X (n=56); X structural abnormality (n=26); X mosaicism without structural abnormality (n=41); X mosaicism with structural abnormality (n=71). Clinical characteristics and growth response parameters were compared over 3 years of GH treatment.

RESULTS

The baseline Ht standard deviation score (SDS) of all patients was -2.85±0.86. The baseline Ht SDS, body mass index SDS, and chronological age (years)-bone age (years) were significantly different based on chromosomal abnormalities. The growth velocity (GV; cm/yr) in the first year was the highest and significantly different among the groups. The GV in the second year also showed an increase in the X mosaicism without structural abnormality group compared with the monosomy X group. The change in Ht SDS (ΔHt SDS) over 3 years was not statistically different between karyotypes.

CONCLUSION

The response to 3 years of GH therapy did not differ based on the karyotype of TS patients although the initial Ht SDS was the lowest in the monosomy X group.

Lymphedema in Turner syndrome: correlations with phenotype and karyotype

OBJECTIVES

Lymphedema (LD) in Turner syndrome (TS) is a commonly reported comorbidity, though its associations with karyotype and other comorbidities are poorly understood. Characteristics of patients with TS and LD, including correlation with phenotype and karyotype, are described.

METHODS

Medical records of patients with TS seen in two pediatric institutions from 2002 to 2020 were retrospectively reviewed. Demographic data (age, presentation onset, clinical features, genetics, LD presence, investigations, treatments) were collected.

RESULTS

393 girls with TS with mean age of 12.5 years (SD: 5.7) were identified. LD was noted in 37 % of patients (n=146). Among the 112 patients with TS and documentation of onset of LD, LD was noted within the first year of life in 78.6 % (n=88). 67.6 % (n=96) of total patients with TS and LD had non-mosaic 45, X karyotype. Frequency of webbed neck was significantly greater in girls with TS and LD compared with girls without LD (58 vs. 7 %, p<0.001). Congenital heart anomalies, hypertension, and renal anomalies were also more common in girls with LD. Nail abnormalities with presence of hypoplastic or dysplastic nails were significantly associated with LD (OR: 6.784, 95 % CI 4.235-11.046). The number of girls reporting presence of LD decreased with age.

CONCLUSIONS

LD in TS often occurs within the first year of life, is less prevalent in older children and adolescents, and is significantly associated with 45, X karyotype, presence of webbed neck, nail changes, congenital heart anomalies, and renal anomalies.

The Effects of Growth Hormone Treatment Beyond Growth Promotion in Patients with Genetic Syndromes: A Systematic Review of the Literature

Recombinant human growth hormone therapy (rhGH) has been widely accepted as the safe treatment for short stature in children with such genetic syndromes as Prader-Willi syndrome and Turner or Noonan syndrome. Some patients with short stature and rare genetic syndromes are treated with rhGH as growth hormone-deficient individuals or as children born small for their gestational age. After years of experience with this therapy in syndromic short stature, it has been proved that there are some aspects of long-term rhGH treatment beyond growth promotion, which can justify rhGH use in these individuals. This paper summarizes the data of a literature review of the effects of rhGH treatment beyond growth promotion in selected genetic syndromes. We chose three of the most common syndromes, Prader-Willi, Turner, and Noonan, in which rhGH treatment is indicated, and three rarer syndromes, Silver-Russel, Kabuki, and Duchenne muscular dystrophy, in which rhGH treatment is not widely indicated. Many studies have shown a significant impact of rhGH therapy on body composition, resting energy expenditure, insulin sensitivity, muscle tonus, motor function, and mental and behavioral development. Growth promotion is undoubtedly the primary benefit of rhGH therapy; nevertheless, especially with genetic syndromes, the additional effects should also be considered as important indications for this treatment.

Live birth rate after oocyte donation in females diagnosed with turner syndrome: a systematic review and meta-analysis

BACKGROUND

An enduring challenge for women diagnosed with Turner syndrome (TS) is infertility. Oocyte donation (OD) offers a chance of pregnancy for these patients. However, current data on pregnancy outcomes are inadequate. Hence, this systematic review aims to explore the clinical outcomes of OD in patients with TS.

METHODS

A systematic search was conducted in PubMed, Web of Sciences, Scopus, and Embase for relevant papers from 1 January 1990 to 30 November 2023. Our primary research objective is to determine the live birth rate among women with TS who have undergone in vitro fertilization (IVF) using OD for fertility purposes. Specifically, we aim to calculate the pooled live birth rates per patient and per embryo transfer (ET) cycle. For secondary outcomes, we have analyzed the rates of clinical pregnancy achievement per ET cycle and the incidence of gestational hypertensive complications per clinical pregnancy. Prevalence meta-analyses were performed using STATA 18.0 by utilizing a random-effects model and calculating the pooled rates of each outcome using a 95% confidence interval (CI).

RESULTS

A total of 14 studies encompassing 417 patients were systematically reviewed. Except for one prospective clinical trial and one prospective cohort study, all other 12 studies had a retrospective cohort design. Our meta-analysis has yielded a pooled live birth rate per patient of 40% (95% CI: 29-51%; 14 studies included) and a pooled live birth rate per ET cycle of 17% (95% CI: 13-20%; 13 studies included). Also, the pooled clinical pregnancy achievement rate per ET cycle was estimated at 31% (95% CI: 25-36%; 12 studies included). Moreover, the pooled rate of pregnancy-induced hypertensive disorders per clinical pregnancy was estimated at 12% (95% CI: 1-31%; 8 studies included). No publication bias was found across all analyses.

CONCLUSIONS

This study demonstrated promising pregnancy outcomes for OD in patients with TS. Further studies are essential to address not only the preferred techniques, but also the psychological, ethical, and societal implications of these complex procedures for these vulnerable populations.

TRIAL REGISTRATION

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration code CRD42023494273.

Visual Impairment in Women with Turner Syndrome-A 49-Year Literature Review

Aim: Among the severe organ complications occurring in patients with Turner syndrome (TS), ophthalmic dysmorphia and visual impairment are usually marginalized. There are only a few studies that take into account the prevalence of ophthalmic disorders in female patients with TS. Material and methods: Articles in PubMed, Scholar, and Website were reviewed, considering the prevalence of various ocular disorders in patients with X chromosome deficiency. Current standards for the management of patients with TS in the context of the prevalence of ophthalmic disorders were also analyzed. Results: Identification of visual impairment in people is important because it significantly impairs quality of life (QoL) along with other health problems. QoL affects cognitive and behavioral functioning and significantly increases self-esteem, acceptance of treatment, and, consequently, physical and mental health. Low self-esteem makes patients feel helpless and unable to plan their social development. Patients with TS are relatively more frequently diagnosed with various eye defects compared to the healthy population. Therefore, special attention should be paid to the early assessment of the visual system in people with TS to eliminate any factors that could potentially impair their QoL. Conclusions: Patients with TS should be referred to specialist ophthalmologists, pediatricians, or optometrists for preventive care or early treatment of visual impairment. The authors point out the need for comprehensive ophthalmological examinations as standard management in patients with TS.

Psychiatric disorders and comorbidity in women with Turner Syndrome: a retrospective national cohort study

Turner syndrome (TS) is a genetic condition characterized by partial or complete monosomy X. A reduced life expectancy has been shown in TS, depending on an increased risk of aortic dissection, and ischemic heart disease. Studies covering the occurrence of psychiatric conditions are sparse within TS. Several case reports describe concomitant TS and neuropsychiatric abnormalities that may represent a pathogenetic link to genetics, as well as feature correlates of TS. The aim of this study was to determine the presence, and the frequency of psychiatric diagnosis in women with TS in a Swedish cohort followed during 25 years' time. Statistics from the entire female population in Sweden of corresponding age was used as reference. Data were retrieved from clinical examinations and validated from the National Board of Health and Welfare registries for women with TS (n = 487), aged 16 to 84 years, with respect to mental health disorders. The most common diagnoses in TS were mood and anxiety disorders. There was no increase in psychiatric diagnosis within the group with time, nor correlation to specific karyotype or somatic comorbidity as congenital heart disease and hypothyroidism, hormonal treatment, or childbirth. In addition, the frequency of psychiatric diagnosis in TS was lower than in the population-based data. Further investigations are needed in the view of the fact that women with Turner syndrome should not be burdened with more severe diagnoses.

White matter microstructure and functional connectivity in the brains of infants with Turner syndrome

Turner syndrome, caused by complete or partial loss of an X-chromosome, is often accompanied by specific cognitive challenges. Magnetic resonance imaging studies of adults and children with Turner syndrome suggest these deficits reflect differences in anatomical and functional connectivity. However, no imaging studies have explored connectivity in infants with Turner syndrome. Consequently, it is unclear when in development connectivity differences emerge. To address this gap, we compared functional connectivity and white matter microstructure of 1-year-old infants with Turner syndrome to typically developing 1-year-old boys and girls. We examined functional connectivity between the right precentral gyrus and five regions that show reduced volume in 1-year old infants with Turner syndrome compared to controls and found no differences. However, exploratory analyses suggested infants with Turner syndrome have altered connectivity between right supramarginal gyrus and left insula and right putamen. To assess anatomical connectivity, we examined diffusivity indices along the superior longitudinal fasciculus and found no differences. However, an exploratory analysis of 46 additional white matter tracts revealed significant group differences in nine tracts. Results suggest that the first year of life is a window in which interventions might prevent connectivity differences observed at later ages, and by extension, some of the cognitive challenges associated with Turner syndrome.

Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology

Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long-term results vary based on the underlying anatomy, pathology, and patient selection, as well as surgeon expertise. The first installment of this Valve-Sparing Aortic Root Replacement State-of-the-Art Review article addresses patient anatomy and physiology as it relates to candidacy for VSRR.

Refractory hypertension complicated with Turner syndrome: A case report

Hypertension is commonly classified into essential hypertension and secondary hypertension, although definitive classification can be challenging in some cases. Here, we discussed a patient who admitted for refractory hypertension, exhibiting various clinical manifestations including inadequate estrogen secretion, underdeveloped secondary sexual characteristics, primary amenorrhea, short stature, multiple moles, and somatic abnormalities. The patient was finally diagnosed with Turner syndrome (TS) based on clinical findings and chromosomal analysis. The genetic karyotype identified was 46,X,i(X)(q10).

Malignant hypertension in a patient with Turner syndrome: A case report

RATIONALE

Turner syndrome is characterized by complete or partial loss of the second sex chromosome. In patients with Turner syndrome, hypertension is well described. However, the literature regarding malignant hypertension is scarce. Therefore, an accurate and timely diagnosis and treatment are important.

PATIENT CONCERNS

A 13-year-old female with Turner syndrome presented to the emergency department with malignant hypertension, headache, spraying vomiting, convulsion, and loss of consciousness. Considering her medical history, symptoms, and auxiliary examination, secondary hypertension (primary reninism) was suspected, but without any occupying or hyperplasia in renal and adrenal.

DIAGNOSIS

A type of secondary hypertension, primary reninism.

INTERVENTIONS

The patient was immediately transferred to the pediatric intensive care unit. Subsequently, she was given nifedipine 0.35 mg/kg and captopril 0.35mg/kg to reduce blood pressure (BP), mannitol and furosemide to reduce cranial pressure, and phenobarbital and midazolam to terminate restlessness successively. Three hours later, the BP was consistently higher than 170/120 mm Hg, sodium nitroprusside was pumped intravenously, then, giving oral drug transition. Finally, she was given Valsartan-Amlodipine Tablets (I) (80 mg valsartan and 5 mg amlodipine per day) and bisoprolol (2.5 mg per day).

OUTCOMES

For 2.5 years of follow-up, the BP reduced to 110-130/60-85 mm Hg, heart rate ranged between 65 and 80 bpm, and she could go to school without any headache, convulsion, and syncope.

LESSONS

The clinical phenotype of Turner syndrome is complex and varied, affecting multiple systems and organs. Turner syndrome with malignant hypertension is rare, so we should systematically evaluate secondary hypertension, target-organ damage, and accompanied by standard management when Turner syndrome presents with hypertension.

Cardiac MRI evaluation of aortic biophysical properties in paediatric Turner syndrome

BACKGROUND

Aortopathy in Turner syndrome is associated with aortic dilation, and the risk of dissection is increased when the aortic size index is ≥ 2-2.5 cm/m2. We evaluated the aortic biophysical properties in paediatric Turner syndrome using cardiac MRI to determine their relationship to aortic size index.

METHODS

Turner syndrome patients underwent cardiac MRI to evaluate ventricular function, aortic dimensions, and biophysical properties (aortic stiffness index, compliance, distensibility, pulse wave velocity, and aortic and left ventricular elastance). Spearman correlation examined correlations between these properties and aortic size index. Data was compared to 10 controls.

RESULTS

Of 25 Turner syndrome patients, median age 14.7 years (interquartile range: 11.0-16.8), height z score -2.7 (interquartile range: -2.92 - -1.54), 24% had a bicuspid aortic valve. Turner syndrome had increased diastolic blood pressure (p < 0.001) and decreased left ventricular end-diastolic (p < 0.001) and end-systolic (p = 0.002) volumes compared to controls. Median aortic size index was 1.81 cm/m2 (interquartile range: 1.45-2.1) and 7 had an aortic size index > 2 cm/m2. Aortic and left ventricular elastance were greater in Turner syndrome compared to controls (both p < 0.001). Increased aortic size index correlated with increased aortic elastance (r = 0.5, p = 0.01) and left ventricular elastance (r = 0.59, p = 0.002) but not aortic compliance. Higher ascending aortic areas were associated with increased aortic compliance (r = 0.44, p = 0.03) and left ventricular elastance (r = 0.49, p = 0.01).

CONCLUSION

Paediatric Turner syndrome with similar aortic size index to controls showed MRI evidence of abnormal aortic biophysical properties. These findings point to an underlying aortopathy and provide additional parameters that may aid in determining risk factors for aortic dissection.

Assessment of obstetric characteristics and outcomes associated with pregnancy with Turner syndrome

OBJECTIVE

To assess national-level trends, characteristics, and outcomes of pregnancies with Turner syndrome in the United States.

DESIGN

Cross-sectional study.

SETTING

The Healthcare Cost and Utilization Project's National Inpatient Sample.

SUBJECTS

A total of 17,865,495 hospital deliveries from 2016-2020.

EXPOSURE

A diagnosis of Turner syndrome, identified according to the World Health Organization's International Classification of Disease 10th revision code of Q96.

MAIN OUTCOME MEASURES

Obstetrics outcomes related to Turner syndrome, assessed with inverse probability of treatment weighting cohort and multivariable binary logistic regression modeling.

RESULTS

The prevalence of pregnant patients with Turner syndrome was 7.0 per 100,000 deliveries (one in 14,235). The number of hospital deliveries with patients who have a diagnosis of Turner syndrome increased from 5.0 to 11.7 per 100,000 deliveries during the study period (adjusted-odds ratio [aOR] for 2020 vs. 2016; 2.18, 95% confidence interval [CI] 1.83-2.60). Pregnant patients with Turner syndrome were more likely to have a diagnosis of pregestational hypertension (4.8% vs. 2.8%; aOR 1.65; 95% CI 1.26-2.15), uterine anomaly (1.6% vs. 0.4%; aOR, 3.01; 95% CI 1.93-4.69), and prior pregnancy losses (1.6% vs. 0.3%; aOR 4.70; 95% CI 3.01-7.32) compared with those without Turner syndrome. For the index obstetric characteristics, Turner syndrome was associated with an increased risk of intrauterine fetal demise (10.9% vs. 0.7%; aOR 8.40; 95% CI 5.30-13.30), intrauterine growth restriction (8.5% vs. 3.5%; aOR 2.11; 95% CI 1.48-2.99), and placenta accreta spectrum (aOR 3.63; 95% CI 1.20-10.97). For delivery outcome, pregnant patients with Turner syndrome were more likely to undergo cesarean delivery (41.6% vs. 32.3%; aOR 1.53; 95% CI 1.26-1.87). Moreover, the odds of periviable delivery (22-25 weeks: 6.1% vs. 0.4%; aOR 5.88; 95% CI 3.47-9.98) and previable delivery (<22 weeks: 3.3% vs. 0.3%; aOR 2.87; 95% CI 1.45-5.69) were increased compared with those without Turner syndrome.

CONCLUSIONS

The results of contemporaneous, nationwide assessment in the United States suggest that although pregnancy with Turner syndrome is uncommon this may represent a high-risk group, particularly for intrauterine fetal demise and periviable delivery. Establishing a society-based approach for preconception counseling and antenatal follow-up would be clinically compelling.

Anxiety in Turner syndrome: Engaging community to address barriers and facilitators to diagnosis and care

Turner syndrome (TS), caused by complete or partial loss of the second sex chromosome, is associated with complex medical manifestations. The TS community identifies anxiety as a major contributor to reduced quality of life. The study aimed to improve understanding of anxiety symptomatology, diagnosis, and care in individuals with TS. A mixed methods design integrated community engagement, including community leaders as co-investigators and a community advisory board, an online survey (N = 135), and in-depth interviews (N = 10). The majority of respondents reported that anxiety symptoms occur two or more days per week, with self-advocates reporting more frequent symptoms than caregivers (p = 0.03). Self-advocates reported feeling anxious more often at school/work; both rater groups reported anxiety-related behaviors were most likely to be expressed at home. Insomnia was the most common symptom of anxiety endorsed across age and rater groups (>70%). Anxiety symptoms and triggers changed with age and often were undiagnosed or untreated during childhood. Therapy and medication were reported as helpful by most respondents who had tried these strategies. Qualitative themes included: 'Triggers for anxiety are related to TS', 'Anxiety impacts the whole family', and 'Opportunities for early identification and intervention'.

Resource use and costs of transitioning from paediatric to adult care for patients with chronic endocrine disease

OBJECTIVE

Structured transition of adolescents and young adults with a chronic endocrine disease from paediatric to adult care is important. Until now, no data on time and resources required for the necessary components of the transition process and the associated costs are available.

DESIGN, PATIENTS AND MEASUREMENTS

In a prospective cohort study of 147 patients with chronic endocrinopathies, for the key elements of a structured transition pathway including (i) assessment of patients' disease-related knowledge and needs, (ii) required education and counselling sessions, (iii) compiling an epicrisis and a transfer appointment of the patient together with the current paediatric and the future adult endocrinologist resource consumption and costs were determined.

RESULTS

One hundred and forty-three of 147 enroled patients (97.3%) completed the transition pathway and were transferred to adult care. The mean time from the decision to start the transition process to the final transfer consultation was 399 ± 159 days. Transfer consultations were performed in 143 patients, including 128 patients jointly with the future adult endocrinologist. Most consultations were performed by a multidisciplinary team consisting of a paediatric and adult endocrinologist, psychologist, nurse, and a social worker acting also as a case manager with a median of three team members and lasted 87.6 ± 23.7 min. The mean cumulative costs per patient of all key elements were 519 ± 206 Euros. In addition, costs for case management through the transition process were 104.8 ± 28.0 Euros.

CONCLUSIONS

Using chronic endocrine diseases as an example, it shows how to calculate the time and cost of a structured transition pathway from paediatric to adult care, which can serve as a starting point for sustainable funding for other chronic rare diseases.