1
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Tenuta M, Cangiano B, Rastrelli G, Carlomagno F, Sciarra F, Sansone A, Isidori AM, Gianfrilli D, Krausz C. Iron overload disorders: Growth and gonadal dysfunction in childhood and adolescence. Pediatr Blood Cancer 2024; 71:e30995. [PMID: 38616355 DOI: 10.1002/pbc.30995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 04/16/2024]
Abstract
Hemochromatosis (HC) is characterized by the progressive accumulation of iron in the body, resulting in organ damage. Endocrine complications are particularly common, especially when the condition manifests in childhood or adolescence, when HC can adversely affect linear growth or pubertal development, with significant repercussions on quality of life even into adulthood. Therefore, a timely and accurate diagnosis of these disorders is mandatory, but sometimes complex for hematologists without endocrinological support. This is a narrative review focused on puberty and growth disorders during infancy and adolescence aiming to offer guidance for diagnosis, treatment, and proper follow-up. Additionally, it aims to highlight gaps in the existing literature and emphasizes the importance of collaboration among specialists, which is essential in the era of precision medicine.
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Affiliation(s)
- Marta Tenuta
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Biagio Cangiano
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Giulia Rastrelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | | | - Francesca Sciarra
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Andrea Sansone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | | | - Csilla Krausz
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
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2
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Hasegawa Y, Hasegawa T, Satoh M, Ikegawa K, Itonaga T, Mitani-Konno M, Kawai M. Pubertal induction in Turner syndrome without gonadal function: A possibility of earlier, lower-dose estrogen therapy. Front Endocrinol (Lausanne) 2023; 14:1051695. [PMID: 37056677 PMCID: PMC10088859 DOI: 10.3389/fendo.2023.1051695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 03/30/2023] Open
Abstract
Delayed and absent puberty and infertility in Turner syndrome (TS) are caused by primary hypogonadism. A majority of patients with TS who are followed at hospitals during childhood will not experience regular menstruation. In fact, almost all patients with TS need estrogen replacement therapy (ERT) before they are young adults. ERT in TS is administered empirically. However, some practical issues concerning puberty induction in TS require clarification, such as how early to start ERT. The present monograph aims to review current pubertal induction therapies for TS without endogenous estrogen production and suggests a new therapeutic approach using a transdermal estradiol patch that mimics incremental increases in circulating, physiological estradiol. Although evidence supporting this approach is still scarce, pubertal induction with earlier, lower-dose estrogen therapy more closely approximates endogenous estradiol secretion.
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Affiliation(s)
- Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Mari Satoh
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
| | - Kento Ikegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Clinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
| | - Tomoyo Itonaga
- Department of Pediatrics, Oita University Faculty of Medicine, Oita, Japan
| | - Marie Mitani-Konno
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
| | - Masanobu Kawai
- Department of Bone and Mineral Research, Research Institute, Osaka Women’s and Children’s Hospital, Osaka, Japan
- Department of Gastroenterology, Nutrition, and Endocrinology, Osaka Women’s and Children’s Hospital, Osaka, Japan
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3
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Federici S, Goggi G, Quinton R, Giovanelli L, Persani L, Cangiano B, Bonomi M. New and Consolidated Therapeutic Options for Pubertal Induction in Hypogonadism: In-depth Review of the Literature. Endocr Rev 2022; 43:824-851. [PMID: 34864951 DOI: 10.1210/endrev/bnab043] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Indexed: 01/15/2023]
Abstract
Delayed puberty (DP) defines a retardation of onset/progression of sexual maturation beyond the expected age from either a lack/delay of the hypothalamo-pituitary-gonadal axis activation or a gonadal failure. DP usually gives rise to concern and uncertainty in patients and their families, potentially affecting their immediate psychosocial well-being and also creating longer term psychosexual sequelae. The most frequent form of DP in younger teenagers is self-limiting and may not need any intervention. Conversely, DP from hypogonadism requires prompt and specific treatment that we summarize in this review. Hormone therapy primarily targets genital maturation, development of secondary sexual characteristics, and the achievement of target height in line with genetic potential, but other key standards of care include body composition and bone mass. Finally, pubertal induction should promote psychosexual development and mitigate both short- and long-term impairments comprising low self-esteem, social withdrawal, depression, and psychosexual difficulties. Different therapeutic options for pubertal induction have been described for both males and females, but we lack the necessary larger randomized trials to define the best approaches for both sexes. We provide an in-depth and updated literature review regarding therapeutic options for inducing puberty in males and females, particularly focusing on recent therapeutic refinements that better encompass the heterogeneity of this population, and underlining key differences in therapeutic timing and goals. We also highlight persistent shortcomings in clinical practice, wherein strategies directed at "the child with delayed puberty of uncertain etiology" risk being misapplied to older adolescents likely to have permanent hypogonadism.
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Affiliation(s)
- Silvia Federici
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Giovanni Goggi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Richard Quinton
- Department of Endocrinology, Diabetes & Metabolism, Newcastle-upon-Tyne Hospitals, Newcastle-upon-Tyne NE1 4LP, UK.,Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne NE1 4EP, UK
| | - Luca Giovanelli
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Luca Persani
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Biagio Cangiano
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
| | - Marco Bonomi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20100 Milan, Italy.,Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, 20100 Milan, Italy
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4
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Cerbone M, Katugampola H, Simpson HL, Dattani MT. Approach to the Patient: Management of Pituitary Hormone Replacement Through Transition. J Clin Endocrinol Metab 2022; 107:2077-2091. [PMID: 35262704 PMCID: PMC9202712 DOI: 10.1210/clinem/dgac129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Indexed: 11/19/2022]
Abstract
Hypopituitarism in childhood is a rare, complex disorder that can present with highly variable phenotypes, which may continue into adult life. Pituitary deficits can evolve over time, with unpredictable patterns resulting in significant morbidity and mortality. Hypopituitarism and hypothalamic dysfunction may be associated with challenging comorbidities such as obesity, learning difficulties, behavioral issues, sleep disturbance, and visual impairment. Transition is the purposeful planned movement of adolescents and young adults with chronic conditions from child-centered to adult-oriented health care systems with a shift from parent- to patient-focused care. To achieve effective transition within a health care setting, the inherent challenges involved in the evolution from a dependent child to an independent adult must be recognized. Transition is a critical time medically for patients with hypopituitarism. Complex issues with respect to puberty, attainment of optimal stature, adherence to treatment, and acceptance of the need for life-sustaining medications need to be addressed. For health care professionals, transition is an opportunity for reassessment of the pituitary deficits and the need for lifelong replacement therapies, often against a background of complex psychological issues. We present 4 illustrative cases of hypopituitarism of differing etiologies with diverse clinical presentations. Diagnostic and management processes from clinical presentation to young adulthood are discussed, with a particular focus on needs and outcomes through transition.
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Affiliation(s)
- Manuela Cerbone
- London Centre for Paediatric Endocrinology and Diabetes at Great Ormond Street Children’s Hospital and University College London Hospitals, London WC1N 1EH, UK
- Section of Molecular Basis of Rare Disease, Genetics and Genomic Medicine Programme, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Harshini Katugampola
- London Centre for Paediatric Endocrinology and Diabetes at Great Ormond Street Children’s Hospital and University College London Hospitals, London WC1N 1EH, UK
- Section of Molecular Basis of Rare Disease, Genetics and Genomic Medicine Programme, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Helen L Simpson
- Section of Molecular Basis of Rare Disease, Genetics and Genomic Medicine Programme, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Diabetes and Endocrinology, University College London Hospitals NHS Trust, London NW1 2BU, UK
| | - Mehul T Dattani
- Correspondence: Mehul T. Dattani, MD, GOS UCL Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK. E-mail:
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5
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Abstract
Pediatric endocrinologists often evaluate and treat youth with delayed puberty. Stereotypically, these patients are 14-year-old young men who present due to lack of pubertal development. Concerns about stature are often present, arising from gradual shifts to lower height percentiles on the population-based, cross-sectional curves. Fathers and/or mothers may have also experienced later than average pubertal onset. In this review, we will discuss a practical clinical approach to the evaluation and management of youth with delayed puberty, including the differential diagnosis and key aspects of evaluation and management informed by recent review of the existing literature. We will also discuss scenarios that pose additional clinical challenges, including: (1) the young woman whose case poses questions regarding how presentation and approach differs for females vs males; (2) the 14-year-old female or 16-year-old young man who highlight the need to reconsider the most likely diagnoses, including whether idiopathic delayed puberty can still be considered constitutional delay of growth and puberty at such late ages; and finally (3) the 12- to 13-year-old whose presentation raises questions about whether age cutoffs for the diagnosis and treatment of delayed puberty should be adjusted downward to coincide with the earlier onset of puberty in the general population.
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Affiliation(s)
- Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, North Adelaide, 5006, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, 5000, Australia
| | - Mark R Palmert
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
- Departments of Pediatrics and Physiology, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
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6
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Butler MG, Miller BS, Romano A, Ross J, Abuzzahab MJ, Backeljauw P, Bamba V, Bhangoo A, Mauras N, Geffner M. Genetic conditions of short stature: A review of three classic examples. Front Endocrinol (Lausanne) 2022; 13:1011960. [PMID: 36339399 PMCID: PMC9634554 DOI: 10.3389/fendo.2022.1011960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/20/2022] [Indexed: 11/30/2022] Open
Abstract
Noonan, Turner, and Prader-Willi syndromes are classical genetic disorders that are marked by short stature. Each disorder has been recognized for several decades and is backed by extensive published literature describing its features, genetic origins, and optimal treatment strategies. These disorders are accompanied by a multitude of comorbidities, including cardiovascular issues, endocrinopathies, and infertility. Diagnostic delays, syndrome-associated comorbidities, and inefficient communication among the members of a patient's health care team can affect a patient's well-being from birth through adulthood. Insufficient information is available to help patients and their multidisciplinary team of providers transition from pediatric to adult health care systems. The aim of this review is to summarize the clinical features and genetics associated with each syndrome, describe best practices for diagnosis and treatment, and emphasize the importance of multidisciplinary teams and appropriate care plans for the pediatric to adult health care transition.
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Affiliation(s)
- Merlin G. Butler
- Department of Psychiatry & Behavioral Sciences, University of Kansas Medical Center, Kansas City, KS, United States
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, United States
- *Correspondence: Merlin G. Butler,
| | - Bradley S. Miller
- Pediatric Endocrinology, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Alicia Romano
- Department of Pediatrics, New York Medical College, Valhalla, NY, United States
| | - Judith Ross
- Department of Pediatrics, Nemours Children’s Health, Wilmington, DE, United States
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, United States
| | | | - Philippe Backeljauw
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Vaneeta Bamba
- Division of Endocrinology, Children’s Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Amrit Bhangoo
- Pediatric Endocrinology, Children's Health of Orange County (CHOC) Children’s Hospital, Orange, CA, United States
| | - Nelly Mauras
- Division of Endocrinology, Nemours Children’s Health, Jacksonville, FL, United States
| | - Mitchell Geffner
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, CA, United States
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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7
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Cirrincione LR, Winston McPherson G, Rongitsch J, Sadilkova K, Drees JC, Krasowski MD, Dickerson JA, Greene DN. Sublingual Estradiol Is Associated with Higher Estrone Concentrations than Transdermal or Injectable Preparations in Transgender Women and Gender Nonbinary Adults. LGBT Health 2021; 8:125-132. [PMID: 33439749 DOI: 10.1089/lgbt.2020.0249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: Serum hormone profiles among different feminizing gender-affirming hormone therapies (GAHT) are poorly characterized. To address this gap, we described the serum estrogen profiles of three 17β-estradiol preparations, taken with or without an antiandrogen, using a novel liquid chromatography-mass spectrometry (LC-MS/MS) assay in adults taking feminizing GAHT. Methods: This was a secondary analysis of 93 healthy transgender women and gender nonbinary adults taking feminizing GAHT in a prospective cross-sectional study. Eligible participants took 17β-estradiol (sublingual tablet, transdermal patch, or intramuscular/subcutaneous injection) with or without oral spironolactone for ≥12 months before study entry. We determined serum estrone and estradiol concentrations for each hormone preparation and described the association between estrone and (1) clinically relevant estradiol concentration ranges (≤200 and >200 pg/mL) and (2) antiandrogen use. To achieve our objectives, we described our protocol for developing an LC-MS/MS assay to measure estrone and estradiol concentrations. Results: Estrone concentrations were higher among participants taking sublingual 17β-estradiol tablets compared with transdermal or injectable preparations (p < 0.0001). Estradiol concentrations were higher for injectable versus transdermal preparations (p = 0.0201), but both were similar to sublingual tablet concentrations (p > 0.05). Estradiol >200 pg/mL (vs. ≤200 pg/mL) was associated with higher estrone concentrations among participants taking sublingual 17β-estradiol, but not transdermal or injectable 17β-estradiol. We observed no association between spironolactone and estrone concentrations (p > 0.5). Conclusion: Estrone concentrations were higher among transgender women and gender nonbinary adults taking sublingual 17β-estradiol compared with transdermal or injectable preparations. The role of estrone in clinical monitoring and the influence of other antiandrogens (e.g., cyproterone acetate) on the estrogen profile remain to be determined.
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Affiliation(s)
| | | | | | - Katerina Sadilkova
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington, USA
| | - Julia C Drees
- The Permanente Medical Group Regional Laboratories, Berkeley, California, USA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jane A Dickerson
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.,Department of Laboratories, Seattle Children's Hospital, Seattle, Washington, USA
| | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
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8
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Hasegawa Y, Itonaga T, Ikegawa K, Nishigaki S, Kawai M, Koga E, Sakakibara H, Ross JL. Ultra-low-dose estrogen therapy for female hypogonadism. Clin Pediatr Endocrinol 2020; 29:49-53. [PMID: 32313372 PMCID: PMC7160460 DOI: 10.1297/cpe.29.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/11/2019] [Indexed: 01/13/2023] Open
Abstract
In females, endogenous estrogen secretion increases gradually before pubertal
development. The benefits of low-dose estrogen therapy in patients with Turner syndrome
were originally discussed by Ross et al. and Quigley et
al. These seminal studies used ethinyl estradiol (EE2), starting at a dose of
25 ng/kg/d. We hypothesized that the initial dosage of estrogen could be titrated to more
closely mimic physiological increments of endogenous estrogen. Therefore, our recent study
initiated EE2 treatment at a dosage of 1–2 ng/kg/d, an ultra-low-dose estrogen therapy in
pediatric patients with Turner syndrome. The ultra-low-dose estrogen therapy in this
syndrome produced a good final height outcome but achieved suboptimal bone mineral density
(BMD). In the present review, we have explained our findings to clarify the merits and
demerits of this new therapy and to promote further discussion and research. This type of
ultra-low-dose estrogen therapy, initiated at an early age, could be ideal for estrogen
replacement in female patients with hypogonadism, such as Turner syndrome.
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Affiliation(s)
- Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tomoyo Itonaga
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Pediatrics, Oita University Faculty of Medicine, Oita, Japan
| | - Kento Ikegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Satsuki Nishigaki
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masanobu Kawai
- Department of Gastroenterology and Endocrinology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Eri Koga
- Department of Gynecology, Yokohama City University Medical Center, Yokohama, Japan
| | - Hideya Sakakibara
- Department of Gynecology, Yokohama City University Medical Center, Yokohama, Japan
| | - Judith L Ross
- Department of Pediatrics, Thomas Jefferson University, Pennsylvania, USA
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9
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Abstract
During puberty, with activation of the hypothalamic pituitary axis that has been quiescent since the neonatal period, linear growth accelerates, secondary sexual characteristics develop, and adult fertility potential and bone mass are achieved, together with psychosocial and emotional maturation.Disordered pubertal onset and progress, either early or late, presents frequently for endocrine care. Where a disorder is found, due either to a central hypothalamic pituitary cause or to primary gonadal failure, pharmacotherapeutic interventions are required to alter the trajectory of disturbed pubertal onset or progress and for maintenance of adolescent and adult sex hormone status. This paper describes pharmacologic interventions used for pubertal disorders but is not intended to address the diagnostic cascade in detail.
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Affiliation(s)
- Margaret Zacharin
- Department of Endocrinology, Royal Children's Hospital, Parkville, VIC, Australia.
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10
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Gravholt CH, Viuff MH, Brun S, Stochholm K, Andersen NH. Turner syndrome: mechanisms and management. Nat Rev Endocrinol 2019; 15:601-614. [PMID: 31213699 DOI: 10.1038/s41574-019-0224-4] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Turner syndrome is a rare condition in women that is associated with either complete or partial loss of one X chromosome, often in mosaic karyotypes. Turner syndrome is associated with short stature, delayed puberty, ovarian dysgenesis, hypergonadotropic hypogonadism, infertility, congenital malformations of the heart, endocrine disorders such as type 1 and type 2 diabetes mellitus, osteoporosis and autoimmune disorders. Morbidity and mortality are increased in women with Turner syndrome compared with the general population and the involvement of multiple organs through all stages of life necessitates a multidisciplinary approach to care. Despite an often conspicuous phenotype, the diagnostic delay can be substantial and the average age at diagnosis is around 15 years of age. However, numerous important clinical advances have been achieved, covering all specialty fields involved in the care of girls and women with Turner syndrome. Here, we present an updated Review of Turner syndrome, covering advances in genetic and genomic mechanisms of disease, associated disorders and multidisciplinary approaches to patient management, including growth hormone therapy and hormone replacement therapy.
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Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Mette H Viuff
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sara Brun
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Centre for Rare Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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