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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: 584] [Impact Index Per Article: 83.4] [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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Green T, Bade Shrestha S, Chromik LC, Rutledge K, Pennington BF, Hong DS, Reiss AL. Elucidating X chromosome influences on Attention Deficit Hyperactivity Disorder and executive function. J Psychiatr Res 2015; 68:217-25. [PMID: 26228422 PMCID: PMC4528918 DOI: 10.1016/j.jpsychires.2015.06.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/27/2015] [Accepted: 06/25/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To identify distinct behavioral and cognitive profiles associated with ADHD in Turner syndrome (TS), relative to idiopathic ADHD and neurotypical controls, in order to elucidate X-linked influences contributing to ADHD. METHODS We used a multilevel-model approach to compare 49 girls with TS to 37 neurotypical females, aged 5-12, on established measures of behavior (BASC-2) and neurocognitive function (NEPSY). We further compared girls with TS to BASC-2 and NEPSY age-matched reference data obtained from children with idiopathic ADHD. RESULTS Within the TS group, 51% scored at or above the "at-risk" range for ADHD-associated behaviors on the BASC-2 (TS/+ADHD). The BASC-2 behavioral profile in this TS/+ADHD-subgroup was comparable to a reference group of boys with ADHD with respect to attentional problems and hyperactivity. However, the TS/+ADHD-subgroup had significantly higher hyperactivity scores relative to a reference sample of girls with ADHD (p = 0.016). The behavioral profile in TS was associated with significantly lower attention and executive function scores on the NEPSY relative to neurotypical controls (p = 0.015); but was comparable to scores from a reference sample of children with idiopathic ADHD. Deficits in attention and executive function were not observed in girls with TS having low levels of ADHD-associated behavior (TS/-ADHD). CONCLUSIONS ADHD-associated behavioral and cognitive problems in TS are prevalent and comparable in severity to those found in children with idiopathic ADHD. The ADHD phenotype in TS also appears relatively independent of cognitive features typically associated with TS, like visuospatial weaknesses. These findings suggest that X-linked haploinsufficiency and downstream biological effects contribute to increased risk for ADHD.
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Affiliation(s)
- Tamar Green
- Center for Interdisciplinary Brain Sciences Research, Stanford, CA 94305, USA; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel.
| | | | - Lindsay C Chromik
- Center for Interdisciplinary Brain Sciences Research, Stanford, CA 94305, USA
| | - Keetan Rutledge
- Center for Interdisciplinary Brain Sciences Research, Stanford, CA 94305, USA
| | - Bruce F Pennington
- Center for Interdisciplinary Brain Sciences Research, Stanford, CA 94305, USA; University of Denver, Department of Psychology, Denver, CO 80210, USA
| | - David S Hong
- Center for Interdisciplinary Brain Sciences Research, Stanford, CA 94305, USA; Department of Psychiatry and Behavioral Sciences, Stanford, CA 94305, USA
| | - Allan L Reiss
- Center for Interdisciplinary Brain Sciences Research, Stanford, CA 94305, USA; Department of Psychiatry and Behavioral Sciences, Stanford, CA 94305, USA; Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA
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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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Vinck A, Maassen BAM, Hulstijn W, Diender MG, Mullaart RA, Rotteveel JJ, Nijhuis-van der Sanden MWG. Motor sequence learning in children with spina bifida. Dev Neuropsychol 2012; 37:601-16. [PMID: 23066938 DOI: 10.1080/87565641.2012.697502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cognitive and motor problems are common in children with spina bifida (SB), particularly in those children with cerebral malformations (SBM). Little is known about how these conditions affect motor learning. This study examines motor sequence learning in children with SB, SBM, and healthy controls. Assessment consisted of neuropsychological tests, a simple drawing task, and a spatial motor sequence learning task. Implicit motor learning was unaffected in children with SB(M), and their sequence learning ability was also similar to that of controls. However, both groups (SB and SBM) showed impaired motor performance. The role of cerebellar malformation with SB(M) is discussed.
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Affiliation(s)
- Anja Vinck
- Department of Medical Psychology/Pediatric Neurology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Lepage JF, Clouchoux C, Lassonde M, Evans AC, Deal CL, Théoret H. Abnormal motor cortex excitability is associated with reduced cortical thickness in X monosomy. Hum Brain Mapp 2011; 34:936-44. [PMID: 22102524 DOI: 10.1002/hbm.21481] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 07/27/2011] [Accepted: 09/09/2011] [Indexed: 11/05/2022] Open
Abstract
Turner syndrome (TS) is a noninherited genetic disorder caused by the absence of one or part of one X chromosome. It is characterized by physical and cognitive phenotypes that include motor deficits that may be related to neuroanatomical abnormalities of sensorimotor pathways. Here, we used transcranial magnetic stimulation (TMS) and cortical thickness analysis to assess motor cortex excitability and cortical morphology in 17 individuals with TS (45, X) and 17 healthy controls. Exploratory analysis was performed to detect the effect of parental origin of the X chromosome (X(mat), X(pat)) on both measures. Results showed that long-interval intracortical inhibition was reduced and motor threshold (MT) was increased in TS relative to controls. Areas of reduced thickness were observed in the precentral gyrus of individuals with TS that correlated with MT. A significant difference between X(mat) (n = 11) and X(pat) (n = 6) individuals was found on the measure of long-interval intracortical inhibition. These findings demonstrate the presence of converging anatomical and neurophysiological abnormalities of the motor system in X monosomy.
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Ganou M, Grouios G. Cerebral laterality in Turner syndrome: a critical review of the literature. Child Neuropsychol 2008; 14:135-47. [PMID: 17943479 DOI: 10.1080/09297040701346099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Turner syndrome (TS) is a genetic disorder in females characterized by the complete or partial absence of one X chromosome. Its most consistent physical features include short stature and ovarian dysgenesis. TS individuals demonstrate a characteristic neurocognitive profile involving weaknesses in visuospatial processing. The hypothesis of defective right hemisphere specialization has been offered to explain the visuospatial deficits in TS. In contrast, an alternative explanation proposes a more uniform dysfunction of the left and right hemispheres, based on findings of symmetrical abnormalities. This article presents an overview of the two hypotheses, along with relevant findings on hemispheric specialization with respect to TS. The impact of the genetic and hormonal mechanisms on the neurocognitive profile of TS is also discussed and directions for further empirical research are identified.
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Affiliation(s)
- M Ganou
- Laboratory of Motor Control and Learning, Department of Physical Education and Sport Sciences, Aristotle University of Thessaloniki, Greece
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Stenekes MW, Nicolai JPA, Geertzen JHB, Mulder T. Kinematic Analysis of Hand Movements After Tendon Repair Surgery. Am J Phys Med Rehabil 2008; 87:169-76. [PMID: 17912141 DOI: 10.1097/phm.0b013e3181583b97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although several hand outcome tests exist to judge skill level after hand injury, currently none give insight into how tasks are performed by looking at kinematic parameters. In this article, the clinical value of analyzing kinematic parameters related to the drawing of a triangle on a graphics tablet by healthy subjects and patients with hand injury is discussed. DESIGN In a first experiment 10 healthy subjects drew the triangles as accurately as possible at various speeds. In a second experiment, 67 healthy subjects and 12 patients with flexor tendon injury were measured repeatedly. RESULTS In the first experiment, the analysis showed a high linear correlation between speed and accuracy for each individual (Pearson correlation coefficient >/=0.762, P </= 0.01). The data led to a formula to standardize deviation for drawing speed, so that different measurements can be compared. In the second experiment, these two measurements correlated well (Pearson correlation coefficient = 0.909, P < 0.001), although a learning effect was noticed (5.4% improvement on average). In healthy subjects the dominant hand performed significantly better than the nondominant hand (P < 0.001). Patients performed significantly worse with their injured hand after 6 wks of dynamic splinting than did healthy subjects (P = 0.003). With their uninjured hand, they performed better than the controls. Six weeks after removal of the splint, no kinematic differences could be discovered between patients and controls. CONCLUSION The results show that kinematic parameters of hand movements may be of additional value for assessing functional recovery from hand injury.
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Affiliation(s)
- Martin W Stenekes
- Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
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