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Martin-Giacalone BA, Lin AE, Rasmussen SA, Kirby RS, Nestoridi E, Liberman RF, Agopian AJ, Carey JC, Cragan JD, Forestieri N, Leedom V, Boyce A, Nembhard WN, Piccardi M, Sandidge T, Shan X, Shumate CJ, Stallings EB, Stevenson R, Lupo PJ. Prevalence and descriptive epidemiology of Turner syndrome in the United States, 2000-2017: A report from the National Birth Defects Prevention Network. Am J Med Genet A 2023; 191:1339-1349. [PMID: 36919524 PMCID: PMC10405780 DOI: 10.1002/ajmg.a.63181] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/07/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
The lack of United States population-based data on Turner syndrome limits assessments of prevalence and associated characteristics for this sex chromosome abnormality. Therefore, we collated 2000-2017 data from seven birth defects surveillance programs within the National Birth Defects Prevention Network. We estimated the prevalence of karyotype-confirmed Turner syndrome diagnosed within the first year of life. We also calculated the proportion of cases with commonly ascertained birth defects, assessed associations with maternal and infant characteristics using prevalence ratios (PR) with 95% confidence intervals (CI), and estimated survival probability. The prevalence of Turner syndrome of any pregnancy outcome was 3.2 per 10,000 female live births (95% CI = 3.0-3.3, program range: 1.0-10.4), and 1.9 for live birth and stillbirth (≥20 weeks gestation) cases (95% CI = 1.8-2.1, program range: 0.2-3.9). Prevalence was lowest among cases born to non-Hispanic Black women compared to non-Hispanic White women (PR = 0.5, 95% CI = 0.4-0.6). Coarctation of the aorta was the most common defect (11.6% of cases), and across the cohort, individuals without hypoplastic left heart had a five-year survival probability of 94.6%. The findings from this population-based study may inform surveillance practices, prenatal counseling, and diagnosis. We also identified racial and ethnic disparities in prevalence, an observation that warrants further investigation.
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Affiliation(s)
- Bailey A. Martin-Giacalone
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Angela E. Lin
- Medical Genetics Unit, Mass General for Children, Boston, Massachusetts, USA
| | - Sonja A. Rasmussen
- Department of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
- Division of Population Health Surveillance, South Carolina Department of Health and Environmental Control, Columbia, South Carolina, USA
| | - Russell S. Kirby
- Chiles Center, University of South Florida College of Public Health, Tampa, Florida, USA
| | - Eirini Nestoridi
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Rebecca F. Liberman
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - A. J. Agopian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - John C. Carey
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Janet D. Cragan
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nina Forestieri
- Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
| | - Vinita Leedom
- Division of Population Health Surveillance, South Carolina Department of Health and Environmental Control, Columbia, South Carolina, USA
| | - Aubree Boyce
- Utah Birth Defect Network, Utah Department of Health and Human Services, Salt Lake City, Utah, USA
| | - Wendy N. Nembhard
- Department of Epidemiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Monika Piccardi
- Office of Genetics and People with Special Health Care Needs, Maryland Department of Health, Baltimore, Maryland, USA
| | - Theresa Sandidge
- Division of Epidemiologic Studies, Illinois Department of Public Health, Springfield, Illinois, USA
| | - Xiaoyi Shan
- Arkansas Reproductive Health Monitoring System, Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - Charles J. Shumate
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas, USA
| | - Erin B. Stallings
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Philip J. Lupo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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González-Rodríguez MTA, Brukman-Jiménez SA, Cuero-Quezada I, Corona-Rivera JR, Corona-Rivera A, Serafín-Saucedo G, Aguirre-Salas LM, Bobadilla-Morales L. Identification of a Small Supernumerary Marker Chromosome in a Turner Syndrome Patient with Karyotype mos 46,X,+mar/45,X. Genes (Basel) 2023; 14:genes14020253. [PMID: 36833181 PMCID: PMC9957150 DOI: 10.3390/genes14020253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Turner Syndrome is characterized by a normal X chromosome and the partial or complete absence of a second sexual chromosome. Small supernumerary marker chromosomes are present in 6.6% of these patients. Because of the wide range of Turner syndrome karyotypes, it is difficult to establish a relationship with the phenotype of the patients. We present the case of a female patient with Turner syndrome, insulin resistance, type 2 diabetes, and intellectual disability. The karyotype revealed the presence of mosaicism with a monosomy X cell line and a second line with a small marker chromosome. FISH of two different tissues was used to identify the marker chromosome with probes for X and Y centromeres. Both tissues presented mosaicism for a two X chromosome signal, differing in the percentage of the monosomy X cell percentage. Comparative genomic hybridization with the CytoScanTMHD assay was performed in genomic DNA from peripheral blood, allowing us to determine the size and breakage points of the small marker chromosome. The patient presents a phenotype that combines classic Turner syndrome features and unlikely ones as intellectual disability. The size, implicated genes, and degree of inactivation of the X chromosome influence the broad spectrum of phenotypes resulting from these chromosomes.
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Affiliation(s)
- María Teresa Alejandra González-Rodríguez
- Human Genetics PhD Program, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Human Genetics Institute “Dr. Enrique Corona Rivera”, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Sinhue Alejandro Brukman-Jiménez
- Human Genetics Institute “Dr. Enrique Corona Rivera”, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Cytogenetics Unit, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara 44340, Mexico
| | - Idalid Cuero-Quezada
- Human Genetics PhD Program, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Human Genetics Institute “Dr. Enrique Corona Rivera”, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
| | - Jorge Román Corona-Rivera
- Human Genetics Institute “Dr. Enrique Corona Rivera”, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Center for Registry and Research in Congenital Anomalies (CRIAC), Service of Genetics, Pediatrics Division, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara 44340, Mexico
| | - Alfredo Corona-Rivera
- Human Genetics Institute “Dr. Enrique Corona Rivera”, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Cytogenetics Unit, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara 44340, Mexico
| | - Graciela Serafín-Saucedo
- Cytogenetics Unit, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara 44340, Mexico
| | - Liuba M. Aguirre-Salas
- Service of Pediatric Endocrinology, Pediatrics Division, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara 44340, Mexico
| | - Lucina Bobadilla-Morales
- Human Genetics Institute “Dr. Enrique Corona Rivera”, Department of Molecular Biology and Genomics, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara 44340, Mexico
- Cytogenetics Unit, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara 44340, Mexico
- Center for Registry and Research in Congenital Anomalies (CRIAC), Service of Genetics, Pediatrics Division, Hospital Civil de Guadalajara Dr. Juan I. Menchaca, Guadalajara 44340, Mexico
- Correspondence: ; Tel.: +52-1-3336189326 or +52-1-3336180362
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Swauger S, Backeljauw P, Hornung L, Shafer J, Casnellie L, Gutmark-Little I. Age at and indication for diagnosis of Turner syndrome in the pediatric population. Am J Med Genet A 2021; 185:3411-3417. [PMID: 34390317 DOI: 10.1002/ajmg.a.62459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/30/2021] [Accepted: 07/09/2021] [Indexed: 01/15/2023]
Abstract
Early diagnosis of Turner syndrome (TS) enables timely intervention and may improve outcomes, but many are still diagnosed late. The objectives of our study were to describe the age and clinical features leading to diagnosis of TS in a large referral center. We hypothesize that newer testing modalities, such as noninvasive prenatal testing (NIPT), may lead to a decline in the age of diagnosis. Medical records of TS patients followed at The Cincinnati Center for Pediatric and Adult TS Care between 1997 and 2016 were reviewed for age at diagnosis, karyotype, and clinical indication(s). Patients (<18 years) were included (n = 239). Thirty-seven percent of patients were diagnosed prenatally or neonatally (≤1 month). The median age of diagnosis was 1.5 (IQR 0.0-10.0) years. If not made during those periods, the median age was 9.3 (IQR 3.2-12.5) years. The most common indications for diagnosis were before birth, unspecified prenatal testing (57%); in neonates/infants, lymphedema (21%); in childhood, short stature (72%); and in adolescence, short stature (45%) followed by pubertal delay with short stature (22%). The age of TS diagnosis in our cohort is young. However, when the diagnosis is not made before 1 year, the median age of diagnosis has not changed in recent years. The age at diagnosis could decrease with prenatal testing, although our study may not have assessed a long enough period of increased use of NIPT. Together with an increase in provider clinical awareness, this may result in more age-appropriate screening of comorbidities and earlier therapeutic intervention.
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Affiliation(s)
- Sarah Swauger
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Philippe Backeljauw
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lindsey Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica Shafer
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lori Casnellie
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Iris Gutmark-Little
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Nunes MR, Pereira TG, Correia HVD, Canabarro ST, Vanz AP, Zen PRG, Rosa RFM. Clinical and cytogenetic characteristics of patients diagnosed with Turner syndrome in a clinical genetics service: cross-sectional retrospective study. SAO PAULO MED J 2021; 139:435-442. [PMID: 34378742 PMCID: PMC9632529 DOI: 10.1590/1516-3180.2020.0470.r2.110321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 03/11/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Turner syndrome (TS) is a rare genetic disease. Understanding its clinical findings contributes to better management of clinical conditions. OBJECTIVE To investigate the clinical and karyotypic characteristics of patients diagnosed with TS at two reference services for clinical genetics in southern Brazil. DESIGN AND SETTING Retrospective cross-sectional study conducted in two clinical genetics services in Porto Alegre (RS), Brazil. METHODS The sample consisted of 59 patients with TS diagnosed from 1993 to 2019. A review of their medical records was performed and a standard protocol was filled out. RESULTS The average age of the patients at diagnosis was 15.9 years, and 40.7% were over 13 years old. The largest proportion of them (42.4%) had been referred from an endocrinology department and their constitution was 45,X (40.7%). The most common clinical findings were short stature (85.7%), hypoplastic/ hyperconvex nails (61.2%), low posterior hairline (52.1%) and cubitus valgus (45.8%). There was no difference regarding the presence of short stature (P = 0.5943), number of dysmorphia (P = 0.143), anatomical regions affected and malformations identified through imaging examinations (P = 1.0000), regarding the presence or absence of 45,X constitution. Only 6% of the patients had used growth hormone and 43%, estrogen. CONCLUSION We found that, in general, patients with TS were being diagnosed late. This has important implications for their treatment. In addition, only a small proportion of the patients were undergoing further examination or evaluation, which appeared to be leading to underdiagnosis of many abnormalities.
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Affiliation(s)
- Maurício Rouvel Nunes
- BSc. Master's Student, Postgraduate Program on Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre (RS), Brazil.
| | - Tiago Godói Pereira
- Undergraduate Student, Department of Clinical Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre (RS), Brazil.
| | - Henry Victor Dutra Correia
- Undergraduate Student, Department of Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre (RS), Brazil.
| | - Simone Travi Canabarro
- PhD. Professor, Department of Nursing, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre (RS), Brazil.
| | - Ana Paula Vanz
- PhD. Professor, Department of Nursing, Faculdades Integradas de Taquara, Taquara (RS), Brazil.
| | - Paulo Ricardo Gazzola Zen
- PhD. Professor, Departments of Clinical Medicine and Clinical Genetics, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre (RS), Brazil.
| | - Rafael Fabiano Machado Rosa
- PhD. Professor, Departments of Clinical Medicine and Clinical Genetics, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre (RS), Brazil.
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Mondal S, Bhattacharjee R, Chowdhury S, Mukhopadhyay S. Karyotype-Phenotype Correlation in Turner Syndrome at a Single Center in Eastern India. Indian Pediatr 2021; 58:34-7. [DOI: 10.1007/s13312-021-2093-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Berglund A, Stochholm K, Gravholt CH. The epidemiology of sex chromosome abnormalities. Am J Med Genet C Semin Med Genet 2020; 184:202-215. [PMID: 32506765 DOI: 10.1002/ajmg.c.31805] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
Abstract
Sex chromosome abnormalities (SCAs) are characterized by gain or loss of entire sex chromosomes or parts of sex chromosomes with the best-known syndromes being Turner syndrome, Klinefelter syndrome, 47,XXX syndrome, and 47,XYY syndrome. Since these syndromes were first described more than 60 years ago, several papers have reported on diseases and health related problems, neurocognitive deficits, and social challenges among affected persons. However, the generally increased comorbidity burden with specific comorbidity patterns within and across syndromes as well as early death of affected persons was not recognized until the last couple of decades, where population-based epidemiological studies were undertaken. Moreover, these epidemiological studies provided knowledge of an association between SCAs and a negatively reduced socioeconomic status in terms of education, income, retirement, cohabitation with a partner and parenthood. This review is on the aspects of epidemiology in Turner, Klinefelter, 47,XXX and 47,XYY syndrome.
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Affiliation(s)
- Agnethe Berglund
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Højbjerg Gravholt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
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Lin AE, Prakash SK, Andersen NH, Viuff MH, Levitsky LL, Rivera-Davila M, Crenshaw ML, Hansen L, Colvin MK, Hayes FJ, Lilly E, Snyder EA, Nader-Eftekhari S, Aldrich MB, Bhatt AB, Prager LM, Arenivas A, Skakkebaek A, Steeves MA, Kreher JB, Gravholt CH. Recognition and management of adults with Turner syndrome: From the transition of adolescence through the senior years. Am J Med Genet A 2019; 179:1987-2033. [PMID: 31418527 DOI: 10.1002/ajmg.a.61310] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/11/2019] [Accepted: 07/18/2019] [Indexed: 12/16/2022]
Abstract
Turner syndrome is recognized now as a syndrome familiar not only to pediatricians and pediatric specialists, medical geneticists, adult endocrinologists, and cardiologists, but also increasingly to primary care providers, internal medicine specialists, obstetricians, and reproductive medicine specialists. In addition, the care of women with Turner syndrome may involve social services, and various educational and neuropsychologic therapies. This article focuses on the recognition and management of Turner syndrome from adolescents in transition, through adulthood, and into another transition as older women. It can be viewed as an interpretation of recent international guidelines, complementary to those recommendations, and in some instances, an update. An attempt was made to provide an international perspective. Finally, the women and families who live with Turner syndrome and who inspired several sections, are themselves part of the broad readership that may benefit from this review.
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Affiliation(s)
- Angela E Lin
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Siddharth K Prakash
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette H Viuff
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology, Department of Pediatrics, Mass General Hospital for Children, Boston, Massachusetts
| | - Michelle Rivera-Davila
- Division of Pediatric Endocrinology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Melissa L Crenshaw
- Medical Genetics Services, Division of Genetics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Lars Hansen
- Department of Otorhinolaryngology, Aarhus University Hospital, Aarhus, Denmark
| | - Mary K Colvin
- Psychology Assessment Center, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Frances J Hayes
- Reproductive Endocrine Unit of the Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Evelyn Lilly
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emma A Snyder
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Shahla Nader-Eftekhari
- Division of Endocrinology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Melissa B Aldrich
- Center for Molecular Imaging, The Brown Institute for Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Ami B Bhatt
- Corrigan Minehan Heart Center, Adult Congenital Heart Disease Program, Massachusetts General Hospital, Boston, Massachusetts.,Yawkey Center for Outpatient Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura M Prager
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Ana Arenivas
- Department of Rehabilitation Psychology/Neuropsychology, TIRR Memorial Hermann Rehabilitation Network, Houston, Texas.,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Anne Skakkebaek
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Marcie A Steeves
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Jeffrey B Kreher
- Department of Pediatrics and Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts
| | - Claus H Gravholt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
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