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Lozano Wun V, Foland‐Ross LC, Jo B, Green T, Hong D, Ross JL, Reiss AL. Adolescent brain development in girls with Turner syndrome. Hum Brain Mapp 2023; 44:4028-4039. [PMID: 37126641 PMCID: PMC10258525 DOI: 10.1002/hbm.26327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 02/08/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023] Open
Abstract
Turner syndrome (TS) is a common sex chromosome aneuploidy in females associated with various physical, cognitive, and socio-emotional phenotypes. However, few studies have examined TS-associated alterations in the development of cortical gray matter volume and the two components that comprise this measure-surface area and thickness. Moreover, the longitudinal direct (i.e., genetic) and indirect (i.e., hormonal) effects of X-monosomy on the brain are unclear. Brain structure was assessed in 61 girls with TS (11.3 ± 2.8 years) and 55 typically developing girls (10.8 ± 2.3 years) for up to 4 timepoints. Surface-based analyses of cortical gray matter volume, thickness, and surface area were conducted to examine the direct effects of X-monosomy present before pubertal onset and indirect hormonal effects of estrogen deficiency/X-monosomy emerging after pubertal onset. Longitudinal analyses revealed that, whereas typically developing girls exhibited normative declines in gray matter structure during adolescence, this pattern was reduced or inverted in TS. Further, girls with TS demonstrated smaller total surface area and larger average cortical thickness overall. Regionally, the TS group exhibited decreased volume and surface area in the pericalcarine, postcentral, and parietal regions relative to typically developing girls, as well as larger volume in the caudate, amygdala, and temporal lobe regions and increased thickness in parietal and temporal regions. Surface area alterations were predominant by age 8, while maturational differences in thickness emerged by age 10 or later. Taken together, these results suggest the involvement of both direct and indirect effects of X-chromosome haploinsufficiency on brain development in TS.
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Affiliation(s)
- Vanessa Lozano Wun
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral SciencesStanford UniversityStanfordCaliforniaUSA
- Department of PsychologyUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Lara C. Foland‐Ross
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral SciencesStanford UniversityStanfordCaliforniaUSA
| | - Booil Jo
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral SciencesStanford UniversityStanfordCaliforniaUSA
| | - Tamar Green
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral SciencesStanford UniversityStanfordCaliforniaUSA
| | - David Hong
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral SciencesStanford UniversityStanfordCaliforniaUSA
| | - Judith L. Ross
- Department of PediatricsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
- Nemours Children's HospitalWilmingtonDelawareUSA
| | - Allan L. Reiss
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral SciencesStanford UniversityStanfordCaliforniaUSA
- Department of PediatricsStanford University School of MedicineStanfordCaliforniaUSA
- Department of RadiologyStanford University School of MedicineStanfordCaliforniaUSA
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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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Jordan TL, Klabunde M, Green T, Hong DS, Ross JL, Jo B, Reiss AL. Longitudinal investigation of cognition, social competence, and anxiety in children and adolescents with Turner syndrome. Horm Behav 2023; 149:105300. [PMID: 36640638 PMCID: PMC9974892 DOI: 10.1016/j.yhbeh.2022.105300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023]
Abstract
Turner syndrome (TS), a common neurogenetic disorder caused by complete or partial absence of an X chromosome in females, is characterized by distinct physical, cognitive, and social-emotional features. Girls with TS typically display average overall intellectual functioning with relative strength in verbal abilities and weaknesses in visuospatial processing, executive function (EF), and social cognition. This study was designed to better understand longitudinal trajectories of cognitive and social-emotional domains commonly affected in TS. Participants included 57 girls with monosomic 45,X TS and 55 age- and verbal-IQ matched girls who completed behavioral, child-report, and parent-report measures across four timepoints. Group differences in visuospatial processing, EF, social cognition, and anxiety were assessed longitudinally. Potential effects of estrogen replacement therapy (ERT) were assessed cross-sectionally on an exploratory basis. The TS group showed poorer performance on measures of visuospatial processing, EF, and social cognition, but not anxiety, compared to controls throughout childhood and adolescence. There were no significant group differences in the trajectory of skill development over time. Exploratory analyses within the TS group revealed that girls who were receiving ERT showed better performance on measures of overall IQ, expressive vocabulary, and visuospatial processing compared to those not receiving ERT. Consistent with existing literature, weaknesses in visuospatial processing, EF, and social competence among girls with TS persisted throughout childhood and adolescence. Exploratory analyses suggest that ERT may help improve some aspects of cognitive function in TS, although other pre-existing, nonhormonal differences between the two TS subgroups may alternatively explain these findings, given our study design. Future studies are needed to examine potential impacts of ERT on cognitive and social-emotional development in TS.
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Affiliation(s)
- Tracy L Jordan
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94304, United States
| | - Megan Klabunde
- Department of Psychology, University of Essex, Valley Road, Wivenhoe Park, Colchester CO4 3SQ, United Kingdom
| | - Tamar Green
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94304, United States
| | - David S Hong
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94304, United States
| | - Judith L Ross
- Department of Pediatrics, Division of Endocrinology, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, United States
| | - Booil Jo
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94304, United States
| | - Allan L Reiss
- Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94304, United States; Department of Radiology, Stanford University School of Medicine, United States; Department of Pediatrics, Stanford University School of Medicine, United States.
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Quigley CA, Fechner PY, Geffner ME, Eugster EA, Ross JL, Habiby RL, Ugrasbul F, Rubin K, Travers S, Antalis CJ, Patel HN, Davenport ML. Prevention of Growth Failure in Turner Syndrome: Long-Term Results of Early Growth Hormone Treatment in the "Toddler Turner" Cohort. Horm Res Paediatr 2021; 94:18-35. [PMID: 34111870 DOI: 10.1159/000513788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/15/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In the randomized "Toddler Turner" study, girls who received growth hormone (GH) starting at ages 9 months to 4 years (early-treated [ET] group) had marked catch-up growth and were 1.6 ± 0.6 SD taller than untreated (early-untreated [EUT]) control girls after 2 years. However, whether the early catch-up growth would result in greater near-adult height (NAH) was unknown. Therefore, this extension study examined the long-term effects of toddler-age GH treatment on height, pubertal development, and safety parameters. METHODS Toddler Turner study participants were invited to enroll in a 10-year observational extension study for annual assessments of growth, pubertal status, and safety during long-term GH treatment to NAH for both ET and EUT groups. RESULTS The ET group was taller than the EUT group at all time points from preschool to maturity and was significantly taller at the onset of puberty (p = 0.016), however, the difference was not significant at NAH. For the full cohort (ET + EUT combined, n = 50) mean (± SD) NAH was 151.2 ± 7.1 cm at age 15.0 ± 1.3 years. NAH standard deviation score (SDS) was within the normal range (>-2.0) for 76% of ET and 60% of EUT subjects (68% overall) and correlated strongly with height SDS at GH start (r = 0.78; p < 0.01), which in turn had a modest inverse correlation with age at GH start (i.e., height SDS declined with increasing age in untreated girls [r = -0.30; p = 0.016]). No new safety concerns arose. CONCLUSION Although the ET group was taller throughout, height SDS at NAH was not significantly different between groups due to catch-down growth of ET girls during lapses in GH treatment after the Toddler study and similar long-term GH exposure overall. Early initiation of GH by age 6 years, followed by uninterrupted treatment during childhood, can prevent ongoing growth failure and enable attainment of height within the normal range during childhood, adolescence, and adulthood.
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Affiliation(s)
| | - Patricia Y Fechner
- Division of Endocrinology, Seattle Children's Hospital, University of Seattle, Seattle, Washington, USA
| | - Mitchell E Geffner
- Center for Diabetes, Endocrinology and Metabolism, The Saban Research Institute, Children's Hospital of Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Erica A Eugster
- Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Judith L Ross
- Department of Pediatric Endocrinology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Reema L Habiby
- Division of Pediatric Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Figen Ugrasbul
- Pediatric Endocrinology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Karen Rubin
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Sharon Travers
- Endocrinology, Children's Hospital Denver, Denver, Colorado, USA.,Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Caryl J Antalis
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Hiren N Patel
- Lilly Corporate Center, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Marsha L Davenport
- Pediatric Endocrinology, University of North Carolina, Chapel Hill, North Carolina, USA
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Morris LA, Tishelman AC, Kremen J, Ross RA. Depression in Turner Syndrome: A Systematic Review. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:769-786. [PMID: 31598804 PMCID: PMC7035188 DOI: 10.1007/s10508-019-01549-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/02/2019] [Accepted: 09/05/2019] [Indexed: 05/19/2023]
Abstract
Turner syndrome (TS) is a genetic condition characterized by partial or complete monosomy X. Alterations in hormonal function, height, and peer relationships, among other features and correlates of TS, appear to be risks for depressive illness. In order to summarize what is known about depression in Turner syndrome, with the aim of determining whether individuals with TS are at increased risk for depression, a literature search and analysis were conducted. In total, 69 studies were identified and 35 met criteria of being peer-reviewed English language articles that collected original data on the experience of depression in individuals with TS. Most studies used patient or parent questionnaires to evaluate depressive symptoms. These studies, a majority of which examined adults and half that examined adolescents, found that individuals with TS experienced more frequent and severe depressive symptoms than individuals without TS diagnoses. Articles studying children with TS did not demonstrate a difference in their depressive experience compared to individuals without TS. Three articles used clinician-administered scales, such as the Structured Clinical Interview for DSM-IV; all diagnosed depression in those with TS at higher rates than others. Five studies relied on expert opinion to evaluate depression. The remaining eight articles were case reports or case series that relied on expert opinion. From these data, we conclude that adolescents and adults with TS are at risk for depression and adulthood appears to be the period of the highest risk. Studies in the last 12 years show consistently more severe depressive symptoms in individuals with TS than in previous years. Implications, risk factors, and recommendations for future research are discussed.
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Affiliation(s)
- Lauren A Morris
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Department of Psychiatry, McLean Hospital, Belmont, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Massachusetts General Hospital/McLean Hospital Child and Adolescent Psychiatry Residency Program, 55 Fruit St. Yawkey 6A, Boston, MA, 02214, USA.
| | - Amy C Tishelman
- Department of Psychiatry, Harvard Medical School and Boston Children's Hospital, Boston, MA, USA
- Department of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jessica Kremen
- Department of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rachel A Ross
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, McLean Hospital, Belmont, MA, USA
- Harvard Medical School, Boston, MA, USA
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Backeljauw P, Klein K. Sex hormone replacement therapy for individuals with Turner syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:13-17. [DOI: 10.1002/ajmg.c.31685] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/05/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Philippe Backeljauw
- Division of Pediatric Endocrinology, The Cincinnati Center for Pediatric and Adult Turner Syndrome Care, Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of Medicine Cincinnati Ohio
| | - Karen Klein
- Division of Pediatric EndocrinologyRady Children's Hospital and University of California San Diego California
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Mauger C, Lancelot C, Roy A, Coutant R, Cantisano N, Le Gall D. Executive Functions in Children and Adolescents with Turner Syndrome: A Systematic Review and Meta-Analysis. Neuropsychol Rev 2018; 28:188-215. [DOI: 10.1007/s11065-018-9372-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/26/2018] [Indexed: 11/30/2022]
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Ruszala A, Wojcik M, Zygmunt-Gorska A, Janus D, Wojtys J, Starzyk JB. Prepubertal ultra-low-dose estrogen therapy is associated with healthier lipid profile than conventional estrogen replacement for pubertal induction in adolescent girls with Turner syndrome: preliminary results. J Endocrinol Invest 2017; 40:875-879. [PMID: 28397183 PMCID: PMC5514173 DOI: 10.1007/s40618-017-0665-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/23/2017] [Indexed: 01/15/2023]
Abstract
PURPOSE The metabolic effects of prepubertal low-dose estrogen replacement (LE) therapy in Turner syndrome (TS) have not been fully investigated to date. The present study aimed to compare glucose and lipids metabolism in adolescents with TS on LE and conventional estrogen replacement (CE). METHODS In 14 TS (mean age 13.8), LE (17β-estradiol, 62.5 μg daily) was introduced before age 12 (mean age 10.5), and followed by a pubertal induction regimen after age 12, and in 14 CE was started after age 12 (mean 14, SD 1.96). Before, and 3 years after starting 17β-estradiol growth velocity, bone age, BMI, and selected parameters of glucose and lipids metabolism were assessed. RESULTS There were no significant differences between LE and CE in the mean levels of any parameter before introduction of 17β-estradiol [total cholesterol (TC): 4.1 vs 4.3 mmol/L, LDL cholesterol (LDLc): 2.2 vs 2.4 mmol/L, HDL cholesterol (HDLc): 1.6 vs 1.4 mmol/L, triglycerides: 0.9 vs 1.0 mmol/L, fasting glucose: 4.2 vs 4.4 mmol/L, post-load glucose: 4.8 vs 5.5 mmol/L; fasting insulin: 6.8 vs 8.0 post-load insulin: 21.3 vs 67.0 μIU/mL, HOMA-IR 1.3 vs 1.6]. After three years of treatment, TC and LDLc levels were significantly lower in LE group (3.8 vs 4.4 mmol/L, p = 0.004; 1.9 vs 2.4 mmol/L, p = 0.03). The other parameters did not differ significantly. There was no negative impact on growth course and bone age advancement nor on BMI in LE group. CONCLUSION Prepubertal LE is associated with healthier lipid profile than CE in girls with TS.
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Affiliation(s)
- Anna Ruszala
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Institute of Pediatrics, Jagiellonian University, Medical College, Wielicka St. 265, 30-663, Krakow, Poland
- Children's University Hospital in Krakow, Wielicka St. 265, 30-663, Krakow, Poland
| | - Malgorzata Wojcik
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Institute of Pediatrics, Jagiellonian University, Medical College, Wielicka St. 265, 30-663, Krakow, Poland.
- Children's University Hospital in Krakow, Wielicka St. 265, 30-663, Krakow, Poland.
| | - Agata Zygmunt-Gorska
- Children's University Hospital in Krakow, Wielicka St. 265, 30-663, Krakow, Poland
| | - Dominika Janus
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Institute of Pediatrics, Jagiellonian University, Medical College, Wielicka St. 265, 30-663, Krakow, Poland
- Children's University Hospital in Krakow, Wielicka St. 265, 30-663, Krakow, Poland
| | - Joanna Wojtys
- Children's University Hospital in Krakow, Wielicka St. 265, 30-663, Krakow, Poland
| | - Jerzy B Starzyk
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Institute of Pediatrics, Jagiellonian University, Medical College, Wielicka St. 265, 30-663, Krakow, Poland
- Children's University Hospital in Krakow, Wielicka St. 265, 30-663, Krakow, Poland
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Quigley CA, Wan X, Garg S, Kowal K, Cutler GB, Ross JL. Effects of low-dose estrogen replacement during childhood on pubertal development and gonadotropin concentrations in patients with Turner syndrome: results of a randomized, double-blind, placebo-controlled clinical trial. J Clin Endocrinol Metab 2014; 99:E1754-64. [PMID: 24762109 PMCID: PMC4154082 DOI: 10.1210/jc.2013-4518] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
CONTEXT The optimal approach to estrogen replacement in girls with Turner syndrome has not been determined. OBJECTIVE The aim of the study was to assess the effects of an individualized regimen of low-dose ethinyl estradiol (EE2) during childhood from as early as age 5, followed by a pubertal induction regimen starting after age 12 and escalating to full replacement over 4 years. DESIGN This study was a prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING The study was conducted at two US pediatric endocrine centers. SUBJECTS Girls with Turner syndrome (n = 149), aged 5.0-12.5 years, were enrolled; data from 123 girls were analyzable for pubertal onset. INTERVENTION(S) Interventions comprised placebo or recombinant GH injections three times a week, with daily oral placebo or oral EE2 during childhood (25 ng/kg/d, ages 5-8 y; 50 ng/kg/d, ages >8-12 y); after age 12, all patients received escalating EE2 starting at a nominal dosage of 100 ng/kg/d. Placebo/EE2 dosages were reduced by 50% for breast development before age 12 years, vaginal bleeding before age 14 years, or undue advance in bone age. MAIN OUTCOME MEASURES The main outcome measures for this report were median ages at Tanner breast stage ≥2, median age at menarche, and tempo of puberty (Tanner 2 to menarche). Patterns of gonadotropin secretion and impact of childhood EE2 on gonadotropins also were assessed. RESULTS Compared with recipients of oral placebo (n = 62), girls who received childhood low-dose EE2 (n = 61) had significantly earlier thelarche (median, 11.6 vs 12.6 y, P < 0.001) and slower tempo of puberty (median, 3.3 vs 2.2 y, P = 0.003); both groups had delayed menarche (median, 15.0 y). Among childhood placebo recipients, girls who had spontaneous breast development before estrogen exposure had significantly lower median FSH values than girls who did not. CONCLUSIONS In addition to previously reported effects on cognitive measures and GH-mediated height gain, childhood estrogen replacement significantly normalized the onset and tempo of puberty. Childhood low-dose estrogen replacement should be considered for girls with Turner syndrome.
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Affiliation(s)
- Charmian A Quigley
- Indiana University School of Medicine (C.A.Q.), Indianapolis, Indiana 46202; Novartis Pharmaceuticals (X.W.), East Hanover, New Jersey 07936; GCE Solutions Inc (S.G.), Bloomington, Illinois 61701; Thomas Jefferson University (K.K.), Philadelphia, Pennsylvania 19107; Gordon Cutler Consultancy, LLC (G.B.C.), Deltaville, Virginia 23043; and Thomas Jefferson University (J.L.R.), Philadelphia, Pennsylvania 19107
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Ross JL, Quigley CA, Cao D, Feuillan P, Kowal K, Chipman JJ, Cutler GB. Growth hormone plus childhood low-dose estrogen in Turner's syndrome. N Engl J Med 2011; 364:1230-42. [PMID: 21449786 PMCID: PMC3083123 DOI: 10.1056/nejmoa1005669] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Short stature and ovarian failure are characteristic features of Turner's syndrome. Although recombinant human growth hormone is commonly used to treat the short stature associated with this syndrome, a randomized, placebo-controlled trial is needed to document whether such treatment increases adult height. Furthermore, it is not known whether childhood estrogen replacement combined with growth hormone therapy provides additional benefit. We examined the independent and combined effects of growth hormone and early, ultra-low-dose estrogen on adult height in girls with Turner's syndrome. METHODS In this double-blind, placebo-controlled trial, we randomly assigned 149 girls, 5.0 to 12.5 years of age, to four groups: double placebo (placebo injection plus childhood oral placebo, 39 patients), estrogen alone (placebo injection plus childhood oral low-dose estrogen, 40), growth hormone alone (growth hormone injection plus childhood oral placebo, 35), and growth hormone-estrogen (growth hormone injection plus childhood oral low-dose estrogen, 35). The dose of growth hormone was 0.1 mg per kilogram of body weight three times per week. The doses of ethinyl estradiol (or placebo) were adjusted for chronologic age and pubertal status. At the first visit after the age of 12.0 years, patients in all treatment groups received escalating doses of ethinyl estradiol. Growth hormone injections were terminated when adult height was reached. RESULTS The mean standard-deviation scores for adult height, attained at an average age of 17.0±1.0 years, after an average study period of 7.2±2.5 years were -2.81±0.85, -3.39±0.74, -2.29±1.10, and -2.10±1.02 for the double-placebo, estrogen-alone, growth hormone-alone, and growth hormone-estrogen groups, respectively (P<0.001). The overall effect of growth hormone treatment (vs. placebo) on adult height was a 0.78±0.13 increase in the height standard-deviation score (5.0 cm) (P<0.001); adult height was greater in the growth hormone-estrogen group than in the growth hormone-alone group, by 0.32±0.17 standard-deviation score (2.1 cm) (P=0.059), suggesting a modest synergy between childhood low-dose ethinyl estradiol and growth hormone. CONCLUSIONS Our study shows that growth hormone treatment increases adult height in patients with Turner's syndrome. In addition, the data suggest that combining childhood ultra-low-dose estrogen with growth hormone may improve growth and provide other potential benefits associated with early initiation of estrogen replacement. (Funded by the National Institute of Child Health and Human Development and Eli Lilly; ClinicalTrials.gov number, NCT00001221.).
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Affiliation(s)
- Judith L Ross
- Jefferson University, Jefferson Medical College, Department of Pediatrics, 1025 Walnut St., Philadelphia, PA 19107, USA.
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Abstract
Turner syndrome (TS) is a relatively common neurogenetic disorder characterized by complete or partial monosomy-X in a phenotypic female. TS is associated with a cognitive profile that typically includes intact intellectual function and verbal abilities with relative weaknesses in visual-spatial, executive, and social cognitive domains. In this report, we review previous and current research related to the cognitive profile of TS. We also discuss how cognitive impairments in this syndrome may reflect integrative rather than modular deficits. For example, the less commonly reported areas of verbal difficulty in TS and certain visual-spatial deficits seem significantly influenced by impairments in executive function and spatially loaded stimuli. We provide a summary of cognitive testing measures used in the assessment of visual-spatial and executive skills, which includes test domain descriptions as well as a comprehensive examination of social cognitive function in TS. This review concludes with a discussion of ecological interpretations regarding the meaning of cognitive deficits in TS at the individual level.
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Affiliation(s)
- David Hong
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
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López MC, Aguilar MJ. Vulnerabilidad social en el síndrome de turner: interacción genes-ambiente. PSICOLOGIA: CIÊNCIA E PROFISSÃO 2009. [DOI: 10.1590/s1414-98932009000200009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
En este trabajo se exponen los fundamentos teóricos que permiten considerar al Síndrome de Turner como un “modelo genético sensible” en el cual analizar asociaciones entre caracteres psicológicos y factores genéticos y ambientales. La investigación en esta línea permitiría dilucidar mecanismos de riesgo ambiental y comprender el grado de “vulnerabilidad” que presentan las mujeres con el síndrome. El Síndrome de Turner es un trastorno genético, no heredable, que se caracteriza por la deleción total o parcial del cromosoma X en el sexo femenino. El estudio de la disfunción social que presentan las mujeres con este síndrome, es decir, de la capacidad para relacionarse con el entorno y la calidad de los vínculos tiene importantes implicaciones en la comprensión de la forma en que actúa el ambiente sobre el desarrollo psicológico, y de cómo a su vez éste se ve afectado por factores genéticos que actúan en interacción.
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Abstract
A síndrome de Turner (ST) ocorre em aproximadamente 1:2.130 nativivos do sexo feminino e os sinais clínicos mais importantes são a baixa estatura e a disgenesia gonadal, levando a amenorréia primária, atraso no desenvolvimento puberal e esterilidade. Podem ser observadas, também, anomalias congênitas e adquiridas e uma grande variabilidade de sinais dismórficos. Assim, a presença de tantos sinais e sintomas, bem como a magnitude dos mesmos pode causar graves conseqüências no funcionamento psicológico e social das pacientes com ST. O objetivo deste artigo consiste numa revisão de literatura a respeito dos aspectos psicológicos da ST. As principais áreas abordadas são: impacto psicossocial da baixa estatura, do atraso no desenvolvimento puberal e da infertilidade, auto-estima, aspectos sociais, identidade de gênero, relacionamentos amorosos e funcionamento sexual, relações familiares, funcionamento cognitivo, doenças psiquiátricas e a presença de uma "doença crônica". Considerações gerais para o acompanhamento psicológico dessas pacientes também são discutidas.
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Lesniak-Karpiak K, Mazzocco MMM, Ross JL. Behavioral assessment of social anxiety in females with Turner or fragile X syndrome. J Autism Dev Disord 2003; 33:55-67. [PMID: 12708580 DOI: 10.1023/a:1022230504787] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Social skills impairment in children with Turner or fragile X syndrome has been documented using parental reports. Anxiety, shyness, and difficulty understanding social cues have been reported for females with Turner syndrome; whereas social withdrawal, avoidance of social interactions, and anxiety are often reported for females with fragile X syndrome. Social interaction anxiety in these two populations may be a framework for understanding the difficulty these children experience in social situations. In the present study, 29 females with Turner syndrome and 21 females with fragile X syndrome ages 6-22 years were compared to females in a comparison group, on a videotaped role-play interaction. Behavioral indices examined included eye-contact maintenance, duration of speech, and body discomfort as observed during the brief interaction. Three of eight such behavioral measures of social skills differentiated the participant groups from each other. Specifically, participants with fragile X required more time to initiate interactions than did participants in either of the remaining groups; and females with Turner syndrome made fewer facial movements than did females in the fragile X or comparison group. Self-report and parental ratings did not suggest higher levels of anxiety in females with Turner or fragile X syndrome, but did reflect higher levels of social difficulty. The authors discuss these findings in terms of understanding the nature of social dysfunction in females with Turner or fragile X syndrome.
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Taback SP, Collu R, Deal CL, Guyda HJ, Salisbury S, Dean HJ, Van Vliet G. Does growth-hormone supplementation affect adult height in Turner's syndrome? Lancet 1996; 348:25-7. [PMID: 8691926 DOI: 10.1016/s0140-6736(96)01267-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND By comparison with historical controls, the effect of treatment with growth hormone on adult height in Turner's syndrome was initially reported as uniformly and strongly positive. Because randomised controlled trials are not near completion, we report our experiences in an open study. METHODS We examined adult height, projected and attained, in 31 patients (17 treated with subcutaneous recombinant human growth hormone, up to 15 mg a week, outside of a controlled trial and 14 untreated contemporaries). FINDINGS Contingency table analysis of attained versus projected height showed significantly higher values in treated patients although only 4 of 17 had final heights of 5 cm or more over projection. Patients' and treatment variables (height, bone-age delay, oestrogen replacement) that interfere with adult height projection confounded the analysis of adult height data. INTERPRETATION Girls with Turner's syndrome should be counselled cautiously about the expectation of a strongly positive effect of treatment on adult height. Completion of the randomised controlled trials to adult height is needed to establish the effect of growth-hormone supplementation on adult height in Turner's syndrome and the psychological effect of treatment.
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Affiliation(s)
- S P Taback
- Endocrinology Services, Montréal Children's Hospital, Canada
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