A decade of growth hormone treatment in girls with Turner syndrome in the UK. UK KIGS Executive Group

Growth Hormone Dosing Estimations Based on Body Weight Versus Body Surface Area

Objective

Both body weight (BW)- and body surface area (BSA)-based dosing regimens have been recommended for growth hormone (rhGH) replacement. The aim was to compare the two regimens to determine if either resulted in inadequate treatment depending on anthropometric factors.

Methods

The retrospective study included children diagnosed with idiopathic isolated growth hormone deficiency. BW-based dosing in mcg/kg/day was converted to BSA in mg/m2/day to determine the equivalent amounts of the given rhGH. Those with a BW-to-BSA ratio of more than 1 were allocated to the “relatively over-dosed group”, while the remaining patients with a ratio of less than 1 were assigned to the “relatively under-dosed” group. Patients with a height gain greater than 0.5 standard deviation score (SDS) at the end of one year were classified as the height gain at goal (HAG), whereas those with a height gain of less than 0.5 SDS were assigned as the height gain not at goal (NHAG).

Results

The study included 60 patients (18 girls, 30%). Thirty-six (60%) patients were classified as HAG. The ratio of dosing based on BW-to-BSA was positively correlated both with the ages and body mass index (BMI) levels of the patients, leveling off at the age of 11 at a BMI of 18 kg/m2. The relative dose estimations (over- and under-dosed groups) differed significantly between the patients classified as HAG or NHAG. Fifty-six percent of NHAG compared to 44% of HAG patients received relatively higher doses, while 79% of HAG compared to 21% of NHAG received relatively lower doses (p=0.006). When the patients were subdivided according to their pubertal status, higher doses were administrated mostly to the pubertal patients in both the NHAG and HAG groups. In the pre-pubertal age group, 73% of NHAG compared to 27% of HAG received relatively higher doses, while 25% of NHAG compared to 75% of HAG received relatively lower doses (p=0.01).

Conclusion

Dosing based on BW may be preferable in both prepubertal and pubertal children who do not show adequate growth responses. In prepubertal children, relatively lower doses calculated based on BW rather than BSA provide similar efficacy at lower costs.

Human Growth and Growth Hormone: From Antiquity to the Recominant Age to the Future

Since antiquity Man has been fascinated by the variations in human (and animal) growth. Stories and art abound about giants and little people. Modern genetics have solved some of etiologies at both extremes of growth. Serious study began with the pathophysiology of acromegaly followed by early attempts at treatment culminating in modern endoscopic surgery and multiple pharmacologic agents. Virtually at the same time experiments with the removal of the pituitary from laboratory animals noted the slowing or stopping of linear growth and then over a few decades the extraction and purification of a protein within the anterior pituitary that restored, partially or in full, the animal's growth. Human growth hormone was purified decades after those from large animals and it was noted that it was species specific, that is, only primate growth hormone was metabolically active in primates. That was quite unlike the beef and pork insulins which revolutionized the care of children with diabetes mellitus. A number of studies included mild enzymatic digestion of beef growth hormone to determine if those "cores" had biologic activity in primates and man. Tantalizing data showed minimal but variable metabolic efficacy leading to the "active core" hypothesis, for these smaller peptides would be amenable to peptide synthesis in the time before recombinant DNA. Recombinant DNA changed the landscape remarkably promising nearly unlimited quantities of metabolically active hormone. Eight indications for therapeutic use have been approved by the Food and Drug Administration and a large number of clinical trials have been undertaken in multiple other conditions for which short stature in childhood is a sign. The future predicts other clinical indications for growth hormone therapy (and perhaps other components of the GH?IGF-1 axis), longer-acting analogues and perhaps a more physiologic method of administration as virtually all methods at present are far from physiologic.

Skeletal disproportion in girls with Turner syndrome and longitudinal change with growth-promoting therapy

OBJECTIVE

Short stature in Turner syndrome (TS) may be accompanied by skeletal disproportion. This retrospective study investigates growth and disproportion from early childhood to adult height.

STUDY DESIGN

Data were collected from 59 girls prior to growth hormone (rhGH) treatment and in 30 girls followed up longitudinally. Standard deviation scores (SDS) for height (Ht), sitting height (SH) and sub-ischial leg length (LL) were compared and a disproportion score (SH SDS - LL SDS) calculated.

RESULTS

In 59 girls, mean (SD) age 6.6 (2.1) years prior to rhGH treatment, LL SDS of -3.4 (1.1) was significantly lower than SH SDS of -1.2 (0.8) [p < .001]. In girls with Ht SDS < -2.0, disproportion score was > +2.0 in 27 (63%), cf eight (50%) with Ht SDS ≥ -2.0. For the longitudinal analysis, skeletal disproportion prior to rhGH was +2.4 (1.1) and +1.7 (1.0) on rhGH but prior to introduction of oestrogen [p < .001]. Disproportion at adult height was +1.1 (0.8), which was less marked than at the earlier time points [p < .001 for both comparisons]. Change in disproportion SDS over the first two years of rhGH predicted overall change in disproportion from baseline to adult height [R² 51.7%, p < .001].

CONCLUSION

TS is associated with skeletal disproportion, which is more severe in the shortest girls and present in only half of those with milder degrees of short stature. Growth-promoting therapy may improve disproportion during both the childhood and pubertal phases of growth. Change in disproportion status two years after starting rhGH helps predict disproportion at adult height.

Insight into the Microcosm of the Human Growth Hormone and Its Interactions with Polymers and Copolymers: A Molecular Dynamics Perspective

Therapeutic proteins nowadays have increasingly been applied for their considerable potential in treating a wide variety of diseases. The effectiveness and potency of native therapeutic proteins are limited by various factors (e.g., stability, blood circulation time, specificity). Over the past years, a great deal of effort has been devoted to developing safe and efficient protein delivery systems. Entrapment of protein into polymeric and copolymeric matrices is common among the different types of protein-based drug formulation. However, despite the massive efforts toward developing therapeutic protein delivery in experimental studies and industrial applications, there is relatively little data on the influence of polymers and copolymers on therapeutic proteins at the atomic and molecular levels. Herein, molecular dynamics (MD) simulations are used to study the effects of biocompatible synthetic polymers including methoxy poly(ethylene glycol) (MPEG), poly(lactic acid) (PLA), and poly(lactic acid) copolymers (poly(lactic-co-glycolic acid)) PLGA and MPEG-PLA(PELA)) on the structure and dynamics of the human growth hormone (hGH), and the results are compared with previous experimental findings. Our results indicate that the hGH conformation remains stable both in pure water and in the presence of polymers, and these results are in good agreement with previous experimental data. It is shown that the MPEG chains are self-assembled and folded into a semicrystalline structure; therefore, only a small portion of the protein interacts with the polymer. The other three polymers, however, interact well with the protein and partially cover its surface. Our findings suggest that the use of these polymers for protein encapsulation has the advantage of reducing protein aggregation and thus increasing drug serum half-life. Eventually, we anticipate that the research results will expand the current knowledge about encapsulation mechanisms and the molecular interactions between hGH and the polymers.

Turner Syndrome: for successful treatment it is necessary to diagnose it early

BACKGROUND

Turner Syndrome (TS) is a chromosomal disorder with short stature as the most common feature. The aim of this paper was to show the characteristics of TS patients treated at our Clinic, with an emphasis on their age at diagnosis and the effect of growth hormone therapy on their final height and height gain.

METHODS

This retrospective study is based on the medical records of 37 female pediatric patients aged 0-18 years treated at the Pediatric Department of the Sestre Milosrdnice University Hospital Center from 1997 to 2017.

RESULTS

Mean age at diagnosis is 7.55±5.13 years. In the observed period a trend towards later diagnosis was shown (P=0.004). Most patients (26) were treated with rhGH. The average height of all patients who reached their final height (N.=30) was 151.49±6.49 cm (standard deviation score [SDS]: -1.73±1.11). The initial height SDS was significantly lower in the treated compared to the untreated patients (P=0.02). The final height was 151.59±7.21 cm (SDS: -1.72±1.3) in the treated and 151.12±5.85 cm (SDS: -1.77±0.94) in the untreated patients. The difference between the initial and final height was significantly greater in the treated patients compared to the untreated patients (30.46 and 16.28 cm, P=0.039). The same was true for the difference between the initial and final height SDS (0.78, or -0.3, P=0.042).

CONCLUSIONS

Based on the results of this research, TS is increasingly diagnosed at a later age. The effect of rhGH therapy was favorable and resulted in a greater height gain in the treated patients.

Real-life GH dosing patterns in children with GHD, TS or born SGA: a report from the NordiNet® International Outcome Study

OBJECTIVE

To describe real-life dosing patterns in children with growth hormone deficiency (GHD), born small for gestational age (SGA) or with Turner syndrome (TS) receiving growth hormone (GH) and enrolled in the NordiNet International Outcome Study (IOS; Nbib960128) between 2006 and 2016.

DESIGN

This non-interventional, multicentre study included paediatric patients diagnosed with GHD (isolated (IGHD) or multiple pituitary hormone deficiency (MPHD)), born SGA or with TS and treated according to everyday clinical practice from the Czech Republic (IGHD/MPHD/SGA/TS: n = 425/61/316/119), France (n = 1404/188/970/206), Germany (n = 2603/351/1387/411) and the UK (n = 259/60/87/35).

METHODS

GH dosing was compared descriptively across countries and indications. Proportions of patients by GH dose group (low/medium/high) or GH dose change (decrease/increase/no change) during years 1 and 2 were also evaluated across countries and indications.

RESULTS

In the Czech Republic, GH dosing was generally within recommended levels. In France, average GH doses were higher for patients with IGHD, MPHD and SGA than in other countries. GH doses in TS tended to be at the lower end of the recommended label range, especially in Germany and the UK; the majority of patients were in the low-dose group. A significant inverse association between baseline height standard deviation score and GH dose was shown (P < 0.05); shorter patients received higher doses. Changes in GH dose, particularly increases, were more common in the second (40%) than in the first year (25%).

CONCLUSIONS

GH dosing varies considerably across countries and indications. In particular, almost half of girls with TS received GH doses below practice guidelines and label recommendations.

Comparison of body surface area versus weight-based growth hormone dosing for girls with Turner syndrome

BACKGROUND/AIMS

Growth Hormone (GH) dosage in childhood is adjusted for body size, but there is no consensus whether body weight (BW) or body surface area (BSA) should be used. We aimed at comparing the biological effect and cost-effectiveness of GH treatment dosed per m2 BSA in comparison with dosing per kg BW in girls with Turner syndrome (TS).

METHODS

Serum IGF-I, GH dose, and adult height gain (AHG) from girls participating in two Dutch and five Swedish studies on the efficacy of GH were analyzed, and the cumulative GH dose and costs were calculated for both dose adjustment methods. Additional medication included estrogens (if no spontaneous puberty occurred) and oxandrolone in some studies.

RESULTS

At each GH dose, the serum IGF-I standard deviation score remained stable over time after an initial increase after the start of treatment. On a high dose (at 1 m2 equivalent to 0.056-0.067 mg/kg/day), AHG was at least equal on GH dosed per m2 BSA compared with dosing per kg BW. The cumulative dose and cost were significantly lower if the GH dose was adjusted for m2 BSA.

CONCLUSION

Dosing GH per m2 BSA is at least as efficacious as dosing per kg BW, and is more cost-effective.

Turner's syndrome: challenges of late diagnosis

Girls and women with Turner's syndrome who come to medical attention older than 12 years present a challenge of medical management. Puberty is already delayed and some compromises have to be made in adjusting the timing of artificially induced puberty to optimise overall outcome with respect to stature, secondary sex characteristics, and psychosocial endpoints. Additionally, individuals who present with primary amenorrhoea to adult services might miss the opportunity for effective growth hormone treatment. Further, induction of puberty regimens lack an evidence base or even clear guidelines for the timing and dose of oestrogen replacement. We have searched the scientific literature to inform management of Turner's syndrome.

Adult height in girls with Turner syndrome treated from before 6 years of age with a fixed per kilogram GH dose

OBJECTIVE

To evaluate adult height (AH) in 25 girls with Turner syndrome (TS) who were treated from before 6 years of age for 10.0 ± 1.7 years with a fixed GH dose of 0.33 mg/kg per week.

PATIENTS AND DESIGN

After a 6-month pretreatment assessment all patients were measured 6-monthly under therapy to assess height SDS (H-SDS) and height velocity (HV) until AH achievement.

RESULTS

Following initial acceleration, HV declined after the first 4 years of therapy. At the end of the sixth year of therapy, H-SDS gain was 1.9 ± 1.1. Thereafter, H-SDS gain from baseline decreased, becoming 0.9 ± 0.9 SDS at AH achievement. Bone maturation velocity did not significantly change throughout the prepubertal period. According to Lyon standards for TS, mean AH SDS was significantly higher than pretreatment H-SDS (P<0.0001), with a mean H-SDS change of 0.9 ± 0.9. However, the prevalence of patients with AH <-2 SDS (according to Sempé standards) was close to those recorded at the start of therapy (16/25 vs 18/25). No significant differences in terms of AH were found between patients with either X monosomy or X-chromosomal abnormalities and between girls with either spontaneous or induced puberty.

CONCLUSIONS

We infer that the therapeutic regimen adopted in this prospective study is sufficient to induce a significant growth acceleration during the first year, but the response waned after 6 years of treatment.

Response to three years of growth hormone therapy in girls with Turner syndrome

PURPOSE

Short stature is the most common finding in patients with Turner syndrome. Improving the final adult height in these patients is a challenge both for the patients and physicians. We investigated the clinical response of patients to growth hormone treatment for height improvement over the period of three years.

METHODS

Review of medical records from 27 patients with Turner syndrome treated with recombinant human growth hormone for more than 3 years was done. Differences in the changes of height standard deviation scores according to karyotype were measured and factors influencing the height changes were analyzed.

RESULTS

The response to recombinant human growth hormone was an increase in the height of the subjects to a mean value of 1.1 standard deviation for subjects with Turner syndrome at the end of the 3-year treatment. The height increment in the first year was highest. The height standard deviation score in the third year was negatively correlated with the age at the beginning of the recombinant human growth hormone treatment. Different karyotypes in subjects did not seem to affect the height changes.

CONCLUSION

Early growth hormone administration in subjects with Turner syndrome is helpful to improve height response to the treatment.

Growth hormone treatment for Turner syndrome in Australia reveals that younger age and increased dose interact to improve response

OBJECTIVE

To investigate response to growth hormone (GH) in the first, second and third years of treatment in the total clinical cohort of Turner syndrome (TS) patients in Australia.

CONTEXT

Short stature is the most common clinical manifestation of TS. GH treatment improves growth.

DESIGN

Response was measured for each year of treatment. Stepwise multiple regression analyses were used to identify factors that significantly influenced response.

PATIENTS

Prepubertal TS patients who completed 1 year (n=176), 2 years (n=148), or 3 years (n=117) of treatment and were currently receiving GH.

MEASUREMENTS

Change in TS specific Height Standard Deviation Score (ΔTSZ) was the main response variable used. Major influencing variables considered included dose, starting age and height, BMI, bone age delay, karyotype, parental height, and interactions between dose and starting age or height.

RESULTS

Response was greatest in first year and declined thereafter (median ΔTSZ: 1st year= +0·705, 2nd year= +0·439, 3rd year= +0·377) despite the median dose increasing [1st year= 5·5 mg/m(2) /week (0·23 mg/kg/week), 2nd year= 6·4(0·24), 3rd year= 7·2(0·26)]. An Age*Dose interaction was identified influencing first, second year, and total ΔTSZ. The ΔTSZ over 3 years was significantly influenced by first-year dose. Dose increments only attenuated the general decline in response. An acceptable first-year response (ΔTSZ>1·01) was achieved by only 17·6% of patients.

CONCLUSIONS

Growth response is greatest and most influenced by dose in the first year. Dose in first year is a major factor contributing to total response. A starting Age*Dose interaction effect was observed such that young girls on a high dose respond disproportionately better. Optimal GH treatment of short stature in TS thus requires early initiation with the highest safe dose in the first year.

Systematic review of the clinical effectiveness of Genotropin (somatropin) in children with short stature

Genotropin (somatropin) is licensed for the treatment of children with growth hormone deficiency, Prader-Willi syndrome, Turner syndrome, chronic renal insufficiency and in children born small for gestational age. This systematic review (SR) evaluated the clinical efficacy and effectiveness of Genotropin in these conditions to inform a NICE Technology Appraisal of growth hormone for the treatment of growth failure in children. Search terms were used to search seven databases, including Medline and Embase, for English language studies. Randomised controlled trials (RCTs) or observational studies investigating Genotropin in children were included. Out of 30 RCTs identified, one reported final height data. Eleven observational studies reported final height and seven were based on the Pfizer International Growth Survey (KIGS). This SR highlights the lack of long-term RCTs reporting final height data and other important qualitative outcomes, such as quality of life. Observational data, such as those from KIGS, remain vital for informing therapy.

Diagnóstico da Síndrome de Turner: a experiência do Instituto Estadual de Diabetes e Endocrinologia - Rio de Janeiro, de 1970 a 2008

OBJETIVOS: descrever a experiência no diagnóstico da Síndrome de Turner (ST), focalizando a distribuição dos cromossomos, a idade, os sinais e sintomas característicos, conforme as fases da vida (lactância, infância, adolescência e adulta). MÉTODOS: estudo descritivo com 178 pacientes, atendidos de 1970 até 2008. Para análise estatística das diferenças percentuais usou-se o Epi-Info-2000 e para as diferenças entre as médias de idades o teste t de Student e o ANOVA. RESULTADOS: os cariótipos encontrados foram: 79 com 45,X (35,4%), 36 com isocromossomo Xq (20,2%) e 63 com outros mosaicos (35,4%). A média de idade do diagnóstico foi de 12,6 anos, sendo menor naquelas com 45,X. Tiveram o diagnóstico feito na lactância 11,3% das pacientes, 25,3% na infância, 51,1% na adolescência e 12,4% na fase adulta. Daquelas diagnosticadas antes dos cinco anos de idade, 70,6% apresentaram 45,X. Os sinais que levaram à suspeita diagnóstica na lactância foram o pescoço alado e o linfedema congênito de pés/mãos associados às dismorfias típicas; na infância e adolescência foi a baixa estatura. Cubitus valgus foi encontrado em 72,5% das pacientes e orelhas anômalas em 65% das pacientes diagnosticadas com menos de um ano de idade. CONCLUSÃO: o diagnóstico da ST é desnecessariamente atrasado, levando-se em consideração que algumas características típicas podem já estar presentes desde o nascimento.

Trends in age and anthropometric data at start of growth hormone treatment for girls with Turner syndrome in Japan

The purpose of this study is to evaluate the trends in age and anthropometric data for girls with Turner syndrome (TS) at start of growth hormone (GH) treatment in Japan. The data for analysis were obtained from a retrospective cohort, the Foundation for Growth Science, Japan. We analyzed trends in starting age of GH treatment for girls with TS in Japan after dividing subjects (n=1,478) into three registration periods: 1991-1994, 1995-1999 and 2000-2004. We also assessed the ratio of the subpopulation of subjects under five years of age. As results, the mean age (standard deviation (SD)) at start of GH treatment was significantly different among the three groups (10.95 (3.63), 10.15 (3.39) and 8.78 (3.61), p<0.0001). The proportion of the subjects under five years of age increased significantly over time (5.11%, 7.11% and 16.85%, p<0.0001). Mean (SD) height SD scores were also significantly different (-3.41 (0.87), -3.26 (0.81) and -3.17 (0.79), p<0.0001). However, the proportions of the karyotype of 45,X were not significantly different among the three groups (p=0.25). We concluded that age and shortness at initiation of GH treatment had been improving over time. However, these favorable trends have not fully met the conditions recommended by international clinical guidelines for TS.

Recombinant growth hormone for children and adolescents with Turner syndrome

BACKGROUND

Turner syndrome (TS) affects about one in 1500 to 2500 live-born females. One of the most prevalent and salient features of the syndrome is extremely short stature. Untreated women are approximately 20 to 21 cm shorter than normal women within their respective populations. Recombinant human growth hormone (hGH) has been used to increase growth and final height in girls who have Turner syndrome.

OBJECTIVES

To assess the effects of recombinant growth hormone in children and adolescents with TS.

SEARCH STRATEGY

MEDLINE, EMBASE, The Cochrane Library, LILACS, BIOSIS, Science Citation Index and reference lists were used to identify relevant trials.

SELECTION CRITERIA

Randomised controlled trials were included if they were carried out in children with TS before achieving final height. Growth hormone had to be administered for a minimum of six months and compared with a placebo or no treatment control condition.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for inclusion criteria and for methodological quality. The primary outcomes were final height and growth. Secondary outcomes included bone age, quality of life, cognitive performance, and adverse effects.

MAIN RESULTS

Four RCTs that included 365 participants after one year of treatment were included. Only one trial reported final height in 61 treated women to be 148 cm and 141 cm in 43 untreated women (mean difference (MD) seven cm, 95% CI 6 to 8). Short-term growth velocity was greater in treated than untreated girls after one year (two trials, MD three cm per year, 95% CI 2 to 4) and after two years (one trial, MD two cm per year, 95% CI 1 to 2.3). Skeletal maturity was not accelerated by treatment with recombinant growth hormone (hGH). Adverse effects were minimally reported.

AUTHORS' CONCLUSIONS

Recombinant human growth hormone (hGH) doses between 0.3 to 0.375 mg/kg/wk increase short-term growth in girls with Turner syndrome by approximately three (two) cm in the first (second) year of treatment. Treatment in one trial increased final height by approximately six cm over an untreated control group. Despite this increase, the final height of treated women was still outside the normal range. Additional trials of the effects of hGH carried out with control groups until final height is achieved would allow better informed decisions about whether the benefits of hGH treatment outweigh the requirement of treatment over several years at considerable cost.

Optimising management in Turner syndrome: from infancy to adult transfer

Turner syndrome can be defined as loss or abnormality of the second X chromosome in at least one cell line in a phenotypic female. The condition occurs in approximately 1 in every 2000 live female births,(1) so that in the UK the prevalence for any year of life is in the region of 200 girls. The condition is much more common in utero, it being estimated that 1-2% of all conceptuses are affected, of whom only 1% will survive to term.

Validation of growth charts for girls with Turner syndrome

Growth charts, which describe the natural course of growth in Turner syndrome (TS) patients, are commonly used in studies in lieu of control groups. While analysing data, various charts produce different final height estimations and height-gain predictions. The choice of an appropriate chart should be the first task when assessing effects of growth hormone treatment. The purpose of this study was to establish the most appropriate growth chart for the subsequent analysis of growth rate in the patients with TS observed initially for a short time without treatment in our clinic. We propose the criteria that a standardised chart should meet. The obtained height-standardised values (height standard deviation score -- Ht SDS) should represent normal distribution with a mean of 0 and standard deviation of 1; their initial mean value and mean change in these values during observation without treatment should not be different from 0. We studied 62 untreated girls with TS using three different growth charts. The values of Ht SDS based on the Lyon chart showed a significant difference from normal distribution (p < 0.05). Only the mean value of an initiaent from 0 (p = 0.088). The mean change of the Ht SDS value based on Lyon and Ranke charts during the follow-up period was not statistically different from 0 (p > 0.05), whereas the difference was statistically significant when the Wisniewski chart was used. Only the Ranke chart correctly characterised TS girls in our clinic. This analysis indicates the importance of careful selection of an appropriate growth chart for an observed population, before applying it to evaluate the effects of hormonal therapy.

Recombinant growth hormone in children and adolescents with Turner syndrome

BACKGROUND

Turner syndrome (TS) affects about one in 1,500 to 2,500 live-born females. One of the most prevalent and salient features of the syndrome is extremely short stature. Untreated women are approximately 20-21 cm shorter than normal women within their respective populations. Recombinant human growth hormone (hGH) has been used to increase growth and final height in women who have Turner syndrome.

OBJECTIVES

To assess the effects of recombinant growth hormone on short-term growth and final height in children and adolescents with Turner syndrome.

SEARCH STRATEGY

Published and unpublished randomised-controlled trials (RCTs) were sought by searching the Cochrane Central Register of Controlled Trials (Central) (2002, Issue 3), Medline (1981 to July 2002), Embase (1980 to June 2002), PubMed (search 30 July, 2002 for entries in last 180 days), Science Citation Index (search 30 July, 2002), BIOSIS (search 30 July, 2002) and Current Controlled Trials (search 30 July, 2002). Article reference lists were assessed for trials and experts and pharmaceutical companies were contacted.

SELECTION CRITERIA

Randomised controlled trials were included if they were carried out in children with Turner Syndrome before achieving final height. Growth hormone had to be administered for a minimum of six months and compared with a placebo or no treatment control condition. A growth or height outcome measure must have been assessed. In addition, in the context of a growth assessment other outcomes reflecting psychological adjustment were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for inclusion criteria and for methodological quality. Data were extracted by one reviewer and checked by a second. The main outcomes were final height (in cm or standard deviation score), growth (in velocity or velocity standard deviation score). Additional outcomes included bone age, quality of life, cognitive performance, and adverse effects. To estimate summary treatment effects, data were pooled using a random effects model (when data were sufficient and appropriate to combine) with calculation of weighted mean differences (WMD) for continuous outcomes.

MAIN RESULTS

Four RCTs that included 211 participants after one year of treatment were included. These were described in six publications. Three studies were included in the analyses of growth outcomes (one study did not report any data). Only one trial reported results on final height. This trial reported that average final height in 40 treated women was 146.2 cm and 141.4 cm in 29 untreated women (mean difference (MD) 4.8 cm, 95% CI 2.2 to 7.4). Short-term growth velocity was greater in treated than untreated girls after one year (two trials, weighted mean difference (WMD) 3.3 cm/yr, 95% CI 2.4 to 4.3) after 18 months (one trial, MD 2.6 cm/yr, 95% CI 2.1 to 3.1) and after two years (one trial, MD 1.8 cm/yr, 95% CI 1.3 to 2.3). Results were similar when reported as growth velocity standard deviation scores. Skeletal maturity was not accelerated by treatment with recombinant growth hormone (hGH). Bone age divided by chronological age was approximately one in both treated and untreated groups in one trial after both one and two years of treatment. One trial selectively reported psychological outcomes that suggested that psychological adjustment was better in girls treated with hGH, but selective reporting leaves these results in some doubt. Adverse effects were minimally reported. There is little evidence of serious short-term adverse effects in these trials, but they are underpowered to detect rare adverse effects.

REVIEWER'S CONCLUSIONS

Recombinant human growth hormone (hGH) doses between 0.3 - 0.375 mg/kg/wk increase short-term growth in girls with Turner Syndrome (TS) by approximately 3 cm in the first year of treatment and by approximately 2 cm per year after 2 years of treatment. There is little evidence on the effects of hGH on final height. Treatment in one trial increased final height by approximately 5 cm over an untreated control group. Despite this increase, the fated control group. Despite this increase, the final height of treated women was still outside the normal range (more than two standard deviations below the normal population mean). Additional trials of the effects of hGH carried out with control groups until final height is achieved would allow better informed decisions about whether the benefits of hGH treatment outweigh the requirement of treatment over several years at considerable cost.

Turner's syndrome in adulthood

Turner's syndrome is the most common chromosomal abnormality in females, affecting 1:2,500 live female births. It is a result of absence of an X chromosome or the presence of a structurally abnormal X chromosome. Its most consistent clinical features are short stature and ovarian failure. However, it is becoming increasingly evident that adults with Turner's syndrome are also susceptible to a range of disorders, including osteoporosis, hypothyroidism, and renal and gastrointestinal disease. Women with Turner's syndrome have a reduced life expectancy, and recent evidence suggests that this is due to an increased risk of aortic dissection and ischemic heart disease. Up until recently, women with Turner's syndrome did not have access to focused health care, and thus quality of life was reduced in a significant number of women. All adults with Turner's syndrome should therefore be followed up by a multidisciplinary team to improve life expectancy and reduce morbidity.

Turner syndrome and Xp deletions: clinical and molecular studies in 47 patients

Although clinical features of Turner syndrome have primarily been explained by the dosage effects of SHOX (short stature homeobox-containing gene) and the putative lymphogenic gene together with chromosomal effects leading to nonspecific features, several matters remain to be determined, including modifying factors for the effects of SHOX haploinsufficiency, chromosomal location of the lymphogenic gene, and genetic factors for miscellaneous features such as multiple pigmented nevi. To clarify such unresolved issues, we examined clinical findings in 47 patients with molecularly defined Xp deletion chromosomes accompanied by the breakpoints on Xp21-22 (group 1; n = 19), those accompanied by the breakpoints on Xp11 (group 2; n = 16), i(Xq) or idic(X)(p11) chromosomes (group 3; n = 8), and interstitial Xp deletion chromosomes (group 4; n = 4). The deletion size of each patient was determined by fluorescence in situ hybridization and microsatellite analyses for 38 Xp loci including SHOX, which was deleted in groups 1-3 and preserved in group 4. The mean GH-untreated adult height was -2.2 SD in group 1 and -2.7 SD in group 2 (GH-untreated adult heights were scanty in group 3). The prevalence of spontaneous breast development in patients aged 12.8 yr or more (mean +/- 2 SD for B2 stage) was 11 of 11 in group 1, 7 of 12 in group 2, and 1 of 7 in group 3. The prevalence of wrist abnormality suggestive of Madelung deformity was 8 of 18 in group 1 and 2 of 23 in groups 2 and 3, and 9 of 18 in patients with spontaneous puberty and 1 of 23 in those without spontaneous puberty. The prevalence of short neck was 1 of 19 in group 1 and 7 of 24 in groups 2 and 3. Soft tissue and visceral anomalies were absent in group 1 preserving the region proximal to Duchenne muscular dystrophy and were often present in groups 2 and 3 missing the region distal to monoamine oxidase A (MAOA). Multiple pigmented nevi were observed in groups 1-3, with the prevalence of 0 of 7 in patients less than 10 yr of age and 15 of 36 in those 10 yr or older regardless of the presence or absence of spontaneous puberty. Turner phenotype was absent in group 4, including a fetus aborted at 21 wk gestation who preserved the region distal to MAOA. The results provide further support for the idea that clinical features in X chromosome aberrations are primarily explained by haploinsufficiency of SHOX and the lymphogenic gene and by the extent of chromosome imbalance in mitotic cells and pairing failure in meiotic cells. Furthermore, it is suggested that 1) expressivity of SHOX haploinsufficiency in the limb and faciocervical regions is primarily influenced by gonadal function status and the presence or absence of the lymphogenic gene, respectively; 2) the lymphogenic gene for soft tissue and visceral stigmata is located between Duchenne muscular dystrophy and MAOA; and 3) multiple pigmented nevi may primarily be ascribed to cooperation between a hitherto unknown genetic factor and an age-dependent factor other than gonadal E.

Long-term results of growth hormone therapy in Turner syndrome

Short stature is one of the main features of Turner syndrome. Today, most patients are treated with growth hormone (GH) to improve adult height. We have reviewed the literature reporting adult height in patients with Turner syndrome treated with GH alone or in combination with oxandrolone. The reported adult heights as well as the height gain over projected or predicted height are still preliminary and vary considerably among studies. There is some evidence that the age of onset of therapy, dose of GH, duration of GH therapy, target height, time of estrogen substitution, or concurrent treatment with oxandrolone affect adult height. The reported height gains over projected height range from -0.20 to +16.0 cm (median: 5.1 cm) in patients treated with GH and from +0.68 cm to +10.3 (median: 6.40 cm) in patients treated with GH and oxandrolone. Thus, the presently available data are extremely varied and need further detailed analysis after all ongoing clinical trials have published the final results of all patients included in the study.

Short stature in Noonan syndrome: response to growth hormone therapy

BACKGROUND

Growth hormone (GH) has been used to promote growth in both the short and long term in a number of dysmorphic syndromes, including Turner syndrome. As this condition shares many clinical features with Noonan syndrome, it would seem logical to treat the latter group with GH.

AIMS

To assess the short and long term response to GH therapy in patients with Noonan syndrome.

METHODS

Analysis of patients with Noonan syndrome in the Pharmacia & Upjohn International Growth Study (this post-marketing database contains data on the majority of patients currently treated with GH in the UK). A questionnaire was also sent to participating clinicians.

RESULTS

Data on 66 patients (54 males) were available for study. At the start of GH therapy children were short, compared with both normal and Noonan children. During the first year of GH therapy height velocity increased from a mean of 4.9 to 7.2 cm per year. For patients treated long term with GH, mean height SDS increased from -2.9 pretreatment to -2.6 after one year and -2.3 after five years. Of the 10 patients at near final height, only one had a height above the 3rd centile for normal adults and above the mean for untreated Noonan patients. The mean increment in final height was 3.1 cm (range -1.1 to 6.5 cm).

CONCLUSIONS

GH therapy in patients with Noonan syndrome will improve height velocity in the short term. Longer-term therapy results in a waning of effect; initial indications are that final height is not improved substantially in most patients.

A multicentre trial of recombinant growth hormone and low dose oestrogen in Turner syndrome: near final height analysis

BACKGROUND

Turner syndrome accounts for 15-20% of childhood usage of growth hormone (GH) in the UK but final height benefit remains uncertain. The most effective strategy for oestrogen replacement is also unclear.

METHODS

Fifty eight girls who, at start of treatment, were of mean age 9.1 years and projected final height 142.2 cm were randomised to receive in year 1, either low dose ethinyloestradiol 50-75 ng/kg/day, GH 28 IU/m(2) surface area/week as a daily injection, or a combination of ethinyloestradiol and GH. After the first year, the ethinyloestradiol treated girls received combination treatment. After two years, girls aged over 12 years were given escalating ethinyloestradiol to promote pubertal development.

RESULTS

Near final height was available for 49 girls at age 16.5 years, 146.8 cm, representing a gain of 4.6 cm, range -7.9 to +11.7 cm. Twelve of the 49 girls gaining 7.5 cm or more were less than 13 years at the start and had received GH for at least four years. Height gain was correlated with greater initial height deficit. Fifteen girls (31%) reached 150 cm or more compared to a predicted 10%. Early supplementation with ethinyloestradiol provided no final height advantage.

CONCLUSIONS

Final height gain was modest at 4.6 cm. Younger, shorter girls gained greatest height advantage from GH. Low dosage ethinyloestradiol before planned induction of puberty was not beneficial.

Health of teenagers in residential care: comparison of data held by care staff with data in community child health records

AIM

To identify whether there are gaps in information available to care staff about the health related needs of one group of teenagers in residential care which could be addressed by reviewing the community child health records.

METHODS

Data were collected on the residents of a children's home during a three month period, comparing information from children's home records with information from community child health records.

RESULTS

Data were collected from children's home records for 36 residents and child health records obtained for 29. Child health records provided the only information on 53% of child protection registrations and 17.5% of statements of special educational needs. Most information on birth history, developmental and early medical history, immunisations, growth, hearing, and colour vision came from the child health records. Immunisation uptake was below the national average, and particularly poor for BCG and school leaver tetanus, low dose diphtheria, and polio boosters. Emotional and behavioural problems were present in 100% of the residents and this information was known to the home. Poor use of "Looking After Children" records was identified, and there was a paucity of information in the home records and child health records about results of annual looked after medical examinations.

CONCLUSION

Important information about the health needs of looked after teenagers was not known to the children's home staff. Community paediatricians should be proactive in identifying and addressing these needs.

SHOX haploinsufficiency and overdosage: impact of gonadal function status

Since its discovery in 1997, knowledge about the SHOX gene has rapidly increased. In this review, we summarise clinical features and diagnostic and therapeutic implications in SHOX haploinsufficiency and overdosage. SHOX haploinsufficiency usually results in mesomelic short stature and Turner skeletal features, including Madelung deformity with puberty, in subjects with normal gonadal function. Thus, identification of early or mild signs of Madelung deformity is pivotal for the diagnosis, and gonadal suppression therapy may serve to mitigate the clinical features. By contrast, SHOX overdosage usually leads to long limbs and tall stature resulting from continued growth into the late teens in subjects with gonadal dysgenesis. Thus, the combination of tall stature and poor pubertal development is the key to diagnosis, and oestrogen therapy can help the prevention of unfavourably tall stature as well as the induction of sexual development. These findings, in conjunction with skeletal assessment in Turner syndrome and expression analysis during human embryogenesis, imply that SHOX functions as a repressor for growth plate fusion and skeletal maturation in the distal limbs and, thus, counteracts the skeletal maturing effects of oestrogens.