The relationship of periaortic fat thickness and cardiovascular risk factors in children with Turner syndrome

Clinical practice guidelines for the care of girls and women with Turner syndrome

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.

The prevalence of hypertension in paediatric Turner syndrome: a systematic review and meta-analysis

Cardiovascular related deaths account for over 40% of the excess mortality in Turner syndrome (TS). Hypertension, a modifiable risk factor for both aortic dilatation and dissection, is more commonly encountered in TS during childhood and adolescence. Treatment of hypertension is currently recommended beyond the age of 16 years in TS to help reduce the risk of aortic dissection. This study aims to determine the prevalence of hypertension in paediatric patients with TS and explore the associated methodologies of blood pressure evaluation reported in these studies. Three online databases were searched (Medline, Embase and Web of Science) for literature which reported a prevalence, or allowed calculation of prevalence, of hypertension in patients with TS who were 18 years of age or younger. Seventeen studies which met the primary eligibility criteria, with a total of 1948 patients, were included. The estimated pooled prevalence of hypertension in children and adolescents with TS was 16% (95% CI: 8.9-24.6%). There was significant heterogeneity detected between the studies. The prevalence of hypertension in those studies which assessed 24-h Ambulatory Blood Pressure Monitoring (ABPM) was 21.1% (95% CI: 15.2-27.6%) compared those which used another method of blood pressure measurement which was 13.5% (95% CI: 5.2-24.4%). Given the impact of hypertension with long-term health outcomes and the reversibility of these same outcomes by addressing abnormal blood pressure, prompt and early diagnosis of hypertension in young girls with TS should be prioritised. We recommend the use of 24-h ABPM in screening for hypertension in the paediatric TS population.

Cardiovascular Disease Risk in Children and Adolescents with Attention Deficit/Hyperactivity Disorder

Objective

The aim of this case-controlled study is to evaluate chronic inflammation, subclinical atherosclerosis and cardiovascular disease risk in children and adolescents with ADHD.

Methods

A total of 51 medication-free children and adolescents with ADHD and 51 healthy controls were included in this study. K-SADS-PL was used to determine the diagnosis of ADHD and other psychiatric disorders. Conners' Parent Rating Scale-Revised Short Form and the Conners' Teacher Rating Scale-Revised Short Form severity of ADHD was used to evaluate severity of ADHD. In order to evaluate subclinical atherosclerosis, common carotid intima media thickness (IMT), epicardial adipose tissue thickness (EAT), and periaortic adipose tissue thickness (PAT) were assessed as well as clinical parameters.

Results

The IMT (0.037 ± 0.005 cm vs. 0.026 ± 0.003 cm), EAT (0.472 ± 0.076 cm vs. 0.355 ± 0.051 cm), and PAT (0.135 ± 0.016 cm vs. 0.118 ± 0.009 cm) measurements were significantly higher in the ADHD group than in the control group. Additionally, partial correlation analyses revealed that a positive correlation was observed between IMT and EAT, and PAT measurements separately. Multivariate linear regression analysis revealed that, body mass index (BMI) positively predicted IMT. Also, age and BMI positively predicted the EAT levels of the subjects with ADHD.

Conclusion

Our results suggest that children and adolescents with ADHD have a risk for cardiovascular disease. For this reason, subclinical atherosclerosis should be taken into consideration in the follow-up and treatment of ADHD for cardiovascular disease risk.

Hyperglycemia in Turner syndrome: Impact, mechanisms, and areas for future research

Turner syndrome (TS) is a common chromosomal disorder resulting from complete or partial absence of the second sex chromosome. Hyperglycemia, ranging from impaired glucose tolerance (IGT) to diabetes mellitus (DM), is common in TS. DM in individuals with TS is associated with an 11-fold excess in mortality. The reasons for the high prevalence of hyperglycemia in TS are not well understood even though this aspect of TS was initially reported almost 60 years ago. Karyotype, as a proxy for X chromosome (Xchr) gene dosage, has been associated with DM risk in TS - however, no specific Xchr genes or loci have been implicated in the TS hyperglycemia phenotype. The molecular genetic study of TS-related phenotypes is hampered by inability to design analyses based on familial segregation, as TS is a non-heritable genetic disorder. Mechanistic studies are confounded by a lack of adequate TS animal models, small and heterogenous study populations, and the use of medications that alter carbohydrate metabolism in the management of TS. This review summarizes and assesses existing data related to the physiological and genetic mechanisms hypothesized to underlie hyperglycemia in TS, concluding that insulin deficiency is an early defect intrinsic to TS that results in hyperglycemia. Diagnostic criteria and therapeutic options for treatment of hyperglycemia in TS are presented, while emphasizing the pitfalls and complexities of studying glucose metabolism and diagnosing hyperglycemia in the TS population.

Evaluation of subclinical cardiovascular risk and cardiac function in children with vesicoureteral reflux: a prospective study

BACKGROUND

Vesicoureteral reflux is a prominent congenital anomaly of the kidney and the urinary tract. Further, renal scarring is known to be related to chronic inflammation. However, there have been limited studies to date regarding the cardiovascular consequences of vesicoureteral reflux.

OBJECTIVE

The aim of this study is to evaluate the possible subclinical atherosclerosis and cardiovascular complications in children with vesicoureteral reflux.

METHODS

Patients with vesicoureteral reflux and age matched healthy controls were prospectively included in this case-control study. Patients were divided into two groups concerning renal scarring status. To assess cardiac functions, carotid artery intima media, epicardial adipose tissue, and periaortic adipose tissue thicknesses were evaluated.

RESULTS

There were 50 patients with vesicoureteral reflux; 26 patients without renal scarring and 24 patients with renal scarring, as well as 40 healthy controls. Myocardial performance indexes (Tei indexes) measured by tissue Doppler echocardiography from septum and left ventricle were significantly increased in study group (for all, p < 0.001). Also, intima media, epicardial adipose tissue, and periaortic adipose tissue thicknesses of the study groups were significantly higher than the control group (for all, p < 0.001). However, no statistical difference was observed between renal scarring (-) and renal scarring (+) groups.

CONCLUSIONS

Results of our study showed early deterioration of cardiac systolic and diastolic functions in children with vesicoureteral reflux regardless of renal scarring. Also, diagnosis of vesicoureteral reflux is an important risk factor for subclinical atherosclerosis, independent of renal scarring, which should be considered in the follow-up of these patients.

Heart and Aorta Anomalies in Turner Syndrome and Relation with Karyotype

Objectives

Turner Syndrome (TS) is associated with a high risk of cardiac anomalies and cardiovascular disease. We aimed to evaluate patients with TS (n=33) for cardiac and aortic pathology using thorax magnetic resonance angiography (MRA).

Subjects and methods

Clinical findings, karyotypes, echocardiogram (ECHO) findings and thorax MRA results were evaluated. Aortic dimensions were measured and standard Z scores of aortic diameters along with aortic size index (ASI) were calculated.

Results

Mean age of the patients was 13.7±3.4 years. MRA revealed cardiovascular pathology in 10 patients (30%). CoA (n=4), aberrant right subclavian artery (n=3), dilatation of the ascending aorta (n=1), tortuosity of the descending aorta (n=1) and fusiform dilatation of the left subclavian artery (n=1) were found. Two of the four patients with CoA found on MRA were detected with ECHO. Mean diameter of the sinotubular junction was found to be elevated [mean±SD: 2.4±1.5]. Z scores for the diameters of the isthmus, ascending aorta and descending aorta were in normal ranges. 45,X patients were found to have significantly higher ASI values than non 45,X patients (p=0.036).

Conclusion

Our findings indicate that patients with TS should be evaluated with MR imaging studies in addition to ECHO to reveal additional subtle cardiac and vascular anomalies. CoA which is very distally located or which has mild nature may not be seen by ECHO. The increase in ASI observed in 45,X patients may herald the development of life-threatening complications. Therefore, frequent follow-up is warranted in these patients.