Iq option é seguro
Revenue Fund Flow Return AUM Expense Dividend. ETF issuers are ranked based on their estimated revenue from their ETFs with exposure to Crude Oil. Estimated revenue for an ETF issuer is calculated by aggregating the estimated revenue of the respective issuer ETFs with exposure to Crude Oil. To get the estimated issuer revenue from a single Crude Oil ETFthe AUM is multiplied by the ETF s expense ratio. ETF Issuer Fund Flow League Table.
ETF issuers are ranked based on their aggregate 3-month fund flows of their ETFs with exposure to Crude Oil. 3-month fund flows is a metric that can be used to gauge the perceived popularity amongst investors of different ETF issuers with ETFs that have exposure to Crude Oil. ETF Issuer Return League Table. ETF issuers are ranked based on their AUM -weighted average 3-month return of their ETFs with exposure to Crude Oil.
ETF Issuer AUM League Table. ETF issuers are ranked based on their aggregate assets under management AUM of their ETFs with exposure to Crude Oil. ETF Issuer Expense League Table. ETF issuers are ranked based on their AUM -weighted average expense ratios of their ETFs with exposure to Crude Oil. The lower the average expense ratio of all U. ETF Issuer Dividend League Table. ETF issuers are ranked based on their AUM -weighted average dividend yield of their ETFs with exposure to Crude Oil.
-listed Crude Oil ETFs for a given issuer, the higher the rank. no_null_sort count_by_id limit 25 Issuer Fund Flow Rank - 3-Month Fund Flow MM Return Rank - Avg. Dividend Yield Revenue Rank - Revenue MM of ETFs issuer_power_ranking_sort_text Barclays Capital - - - - td data-th. - - 1 Barclays Capital Citigroup - 7 - - td data-th. - - 1 Citigroup Credit Suisse - 1 - td data-th. - 1 1 Credit Suisse DWS - - - - td data-th.
- - 1 DWS Invesco - 2 - - td data-th. - - 1 Invesco ProShares - 3 - - td data-th. - - 3 ProShares UBS - 2 - - td data-th. - - 1 UBS USCF - 1 - - td data-th. Last updated on Sep 07, 2020. Momentum Matters in Multi-Factor Small-Cap ETF PSC. The Principal U. A Cost-Effective Route for International Dividend Exposure. Small-Cap Multi-Factor Index ETF PSCas its name implies, is a multi-factor. Across bonds and equities, yields are low in the U.a scenario increasing the allure of. This ETF Matters as Dividends Stay Relevant.
With some market observers saying the worst is over for this year s dividend duress, the. ETF Analyzer. Head-to-Head ETF Comparison. ETF Country Exposure Tool. ETF Screener. Launch Center. Crude Oil News. China ETFs at Risk as Crude Oil Prices Soar. China country-specific ETFs could be among the most at risk if crude oil disruptions and high.
ETF Scorecard November 23 Edition. To help investors keep up with the markets, we present our ETF Scorecard. The Scorecard takes a. ETF Scorecard November 16 Edition. ETF Scorecard November 9 Edition. ETF Scorecard October 26 Edition. Crude Oil Research. Crude Oil s Steep Fall On Global News, Inventory Build. Oil prices fell nearly 2 on Thursday, extending the previous session s 3 drop, to trade a. How to Profit with Leveraged ETFs. Will Growth Worries Hold Down Oil For Rest of 2019.
Supply cuts by the Organization of Petroleum Exporting Countries OPEC have pushed oil prices. Since it tracks S P 500. VIX is a ticker published by CBOE that tracks near-term volatility. Crude Oil vs. Gasoline Differences Between USO UGA. The ongoing evolution of the ETF industry has brought forth a host of previously. 4 Reasons to Use Limit Orders Picture Edition. The ability to trade ETFs intraday, similar to stocks, has not surprisingly drawn the attention.
Source LSEG Information Services USInc. LSEG LSEG 2016. All rights in the XTF data, ratings and or underlying data contained in this communication the XTF information vest in LSEG and or its licensors. Neither LSEG nor its licensors accept any liability arising out of the use of, reliance on or any errors or omissions in iq option é seguro XTF information. No further distribution of the XTF information is permitted without LSEG s express written consent.
LSEG does not promote, sponsor or endorse the content of this communication. ETF Screener ETF Analyzer Mutual Fund to ETF Converter Head-To-Head ETF Comparison ETF Country Exposure Tool ETF Stock Exposure Tool ETF Performance Visualizer ETFdb. com Realtime Ratings ETFdb. com Model Portfolios ETFdb. ETF Launch Center Financial Advisor RIA Center ETFdb. com RSS Feed. ETF News ETF Picks of the Month ETF Category Reports Premium Articles Alphabetical Listing of ETFs Best ETFs Browse ETFs by ETFdb.
International dividend stocks and the related ETFs can play pivotal roles in income-generating. Contact Us About Us Mission Statement Press. You get paid for sending clients to a broker. These affiliate schemes work on the idea of lead generation and or profit sharing. If you operate a web site in the financial or binary options space, or by other means have access to people who might be into trading, there are now a few great binary options affiliate programs, sites and networks through which you can make money on those visitors readers.
How much you get paid depends on how many leads you manage to generate and how many of these leads convert into paying clients for the broker. Affiliate Programs. Find the highest paying programmes here. How to be Profitable With an Affiliate Program. With interest in binary options at an all-time high, there is a lot of money floating around waiting to be earned. Finding the right binary options affiliate program to sign up with can be a tough job as there are almost as many of these programs as there are brokers in the industry.
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Highest Paying Affiliate Scheme IQ Option. Retention rates at IQ Option are excellent making the rev share deal even better. How Affiliates Make Money. When you send a visitor to a broker s site and that visitor signs up, that s called a lead. Typically you don t get paid for a lead unless you negotiate a special deal with the broker.
If that new client then goes on to deposit real money with the broker you get paid according to the commission structure either CPA or Revenue Share, or a so called hybrid deal that will be a combination of these. CPA the CPA structure is a fixed sum of money paid once for every depositing client, normally in the 200 to 600 range depending on your specific deal with the broker. After you receive this payment for a client, you never again make any money on that client. Revenue Share the revshare structure, as it s often called, is less common in the binary industry.
Normally you make a percentage of the profit the broker makes on your client, for life i.the lifetime of the client being an active trader. In short the broker splits its profits with you for all clients you ve sent. You get an agreed percentage of the profits, typically 20-50 depending on how many new clients you send per month. Which Commission Structure is Best. That depends on your visitors and patience. A caveat is that the client has to make at least a specific minimum deposit to trigger a CPA for you, and that minimum amount can vary between affiliate programs and also be negotiable.
CPA is great if you don t send very profitable clients and you want to be paid as soon as possible for you efforts. If the CPA baseline is 15, but most of your clients only deposit 10, you will not earn a CPA. Revshare has the potential to be more profitable than CPA, if you send clients that deposit and trade a lot. But with revshare it can take much longer to make as much money as with CPA, and typically very few traders are high net worth individuals willing to spend a lot on binary trading.
Many affiliates start out with CPA for fast gains, to later have a look at revshare if they intend to be in the field long-term. Many programs will push affiliates towards CPA. Generally because it is better for them. Rev share ensures a fair share of the profits generated from that lead. CPA for binary options affiliates can reach 450- 500 per trader though so if you are unsure about the value of your traffic, CPA is a lucrative option.
24Option Affiliate Program. 24option are a big name in binary options and their affiliate offering reflects this. With their recent move into cfd and forex trading, their brand is growing. Other Affiliate Programs. One drawback for affiliates is the reporting, which is not up to the standard of IQ Option. Rev share is particularly hard to find out relying on reports from affiliate managers. The firm do pay a very good starting CPA of 400 though.
The affiliate program operates around the world, with a growing presence in Ireland. As an established name in the binary options niche, they offer a good starting point for anyone with finance traffic. The move into cfd and forex trading, opens up new monetising routes for traditional binary traffic. 24Option also promote themselves strongly. Affiliates can try and benefit from some of that marketing spend.
Affiliate Networks. The ability to negotiate with individual brands on your own terms is important. In our opinion, affiliate networks offer a slightly less efficient business model than direct contact with the brands. The affiliate market in binary options is murky enough without laying an added layer of potential mistrust. Networks will argue they can agree better terms, ensure brands pay on time and offer all the latest brands.
In our experience, the best deals are found direct with the brands. The respectable brands all pay affiliates on time, and no single network has access to all the leading brands. So given all that, direct relationships are better in our view. There is however, a case for smaller affiliates to use a network. Best Forex Partners. BestForexPartners BFP was founded in 2011 with the idea that affiliate programs are based on the concept of mutual benefits.
So here are a few options. It frees up time and might mean better deals while traffic is low and you lack the clout to influence better terms. Hence, this program provider is willing to provide strong support its affiliates with advanced tools to ensure their success. The strong points about this program provider include. Advanced System Reports High Commissions Large Selection Of Brokers To Work With Multi Payments Methods Proprietary Software For Tracking Performance Wide Range Of Creative And Marketing Tools.
Binary Affiliates Group BAG. BinaryAffiliatesGroup is geared specifically towards the binary options industry. This is good as it shows that they are focused towards the success of their affiliates. Their plus points include. Accurate Reports Attractive Revenue Sharing Plans Easy To Use Dashboard Partners With Strong Leading Brands. The Rushbucks programme has now closed. Brands like 10Trade, Boss Capital and Traderush are no longer operating.
Their programs are very successful in the European market. AFF Europe was established in 2009 with a heavy focus in the gaming and finance industry. They also pride themselves as having one of the most transparent affiliation programs in the industry. The benefits of joining this program provider include.
Attractive Commission Structure Brand Reliability High Conversion Top Notch Support. Affiliation Option. Founded in 2010, Affiliation Option is the only binary options program provider that is currently offering a 100 welcome bonus upon signing up with them. Excellent Support High Commission Payouts Specialist Tailored Programs. Their strong points include. So once you have decided which program provider to sign up with, what is left to do is to promote your affiliate website by providing high quality content for your visitors.
There is no short cut to this, just ask Google. Although this will require a lot of hard work on your part, the payback at the end of the day could be well worth it. Toyota IQ Europe Sales Figures. Monthly and annual sales figures for the Toyota IQ in Europe. 2018 3 2017 2 2016 172 2015 292 2014 3. See how Toyota iQ sales compare to the other models in the minicar segment. Use the dropdown at the top right of this page to find sales figures for any other car model sold in Europe since the early 2000 s.
Car sales statistics are from the following countries Austria, Belgium, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Great Britain, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland. Sources Manufacturers, ANDC, JATO Dynamics. European car sales analysis July 2020 models. European car sales analysis July 2020 brands.
European sales 2020 first half Exotics and Sports Cars. European sales 2020 first half Passenger Vans. I m interested to know how many IQ s there are in the UK. My husband mocks me for my love of Blu, my 1. 0ltr IQ, but I believe the car is a classic design, I see very few on my travels. I recently drove over Glen Shee in Scotland with no trouble at all, loads of fun.
Popular Data. Car Sales by Brand Europe. Car Sales by Brand China. Car Sales by Brand US. Car Sales Data By Brand. Car Sales Data By Manufacturer. Sales Data by Country. Welcome to CarSalesBase, your destination for global automotive sales data, analysis and commentary. Automotive Sales Data. We collect and organize vehicle sales figures from across all the major automotive manufacturers, brands and countries. We hope you enjoy. Example GXE10-0088644, JTEHT05J802063701. Toyota parts catalog.
Search for parts by frame number. Choose model. Camry Gracia. Corolla Ceres. Corolla Axio. Corolla Fielder. Corolla Levin. Corolla Rumion. Corolla Runx. Corolla Spacio. Corona Exiv. Crown Majesta. Dyna Toyoace. Estima Emina. Estima Lucida. Grand Hiace. Granvia Grand Hiace. Land Cruiser. Land Cruiser Prado. Lite Ace Noah. Mark II Wagon Blit. Mark II Wagon Qualis. Mega Cruiser. Passo Sette. Pixis Epoch. Pixis Space. Pixis Truck.
Sprinter Carib. Sprinter Marino. Sprinter Trueno. Town Ace Noah. Vista Ardeo. Didn t find your model. Try searching another region, Toyota Europe, Toyota General, Toyota USA. Current region Toyota Japan Japan. Lufthansa Hikes Its Third-Party Booking Fee Despite the Crisis. Airlines Feeling a Lift From Rocky Mountain Hubs. The 10 Biggest Covid Myths Event Planners Need to Ignore. Subscription Travel Models Offer Encouraging Pandemic Resilience to Inspirato and BeRightBack.
California Boutique Hotelier Deploys Big-Brand Tactics to Seize Growth Opportunities. United States Forums Europe Forums Canada Forums Asia Forums Central America Forums Africa Forums Caribbean Forums Mexico Forums South Pacific Forums South America Forums Middle East Forums. Either way, where are they and how do I access them. Thanks flip flop man, I appreciate you taking the time to reply.
I followed your link and that takes me to the same place I have been getting to lately - namely - the world game and the drop down box with the choices of playing other continents but some time ago I remember playing with having the option of choosing games based on city three letter codes, or specific countries rather than continentsor playing rivers of the world etc etc. Cheers Melanie. - - Message from Tripadvisor staff -. This topic has been closed to new posts due to inactivity. This link any good to you.
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The HELP CENTER pages PLEASE READ The Support Forum Introduction OWNERS How to get to the OWNER S FORUM CONTACT TripAdvisor staff. I think these game my have even been created by members. Traveller IQ game. I remember playing this game and being to play different options such as three letter codes, specific countries. Traveller IQ game - Tripadvisor Support Forum. CONTACT info for ISSUES with VACATION RENTALS HOLIDAY RENTALS CONTACT Info for ISSUES with HOTEL BOOKINGS made on TripAdvisor CONTACT Info for ISSUES with VIATOR Tour bookings CONTACT Info for Issues with LOCU Menus Info for ISSUES with HOTELQUICKLY bookings Info for ISSUES with GALAHOTELS bookings SPAMMER - How do I report one to TA staff.
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How do I ask a question about a specific destination. This is the version of our website addressed to speakers of English in the United States. Air Travel Business Travel Timeshares Vacation Rentals See all raquo. Scientists agree that the earlier in life a child receives early intervention services the better the child s prognosis. All children with autism can benefit from early intervention, and some may gain enough skills to be able to attend mainstream school. Research tells us that early intervention in an appropriate educational setting for at least two years prior to the start of school can result in significant improvements for many young children with autism spectrum disorders ASD.
As soon as autism is diagnosed, early intervention instruction should begin. Effective programs focus on developing communication, social, and cognitive skills. Early diagnosis of ASD, coupled with swift and effective intervention, is paramount to achieving the best possible prognosis for the child. Even at ages as young as six months, diagnosis of ASD is possible.
Regular screenings by pediatric psychiatrists are recommended by the Centers for Disease Control and Prevention CDC. Even if your child is not diagnosed with an ASD before the age of 3, under the Individuals with Disabilities Education Act IDEAyour child may be eligible for services provided by your state. More information on autism and insurance can be found here.
In addition, many insurance companies will provide additional assistance for the coverage of proven therapies. Treatment works to minimize the impact of the core features and associated deficits of ASD and to maximize functional independence and quality of life. The most effective treatments available today are applied behavioral analysis ABAoccupational therapy, speech therapy, physical therapy, and pharmacological therapy.
In 2012, the Missouri Guidelines Initiative summarized the findings from 6 reviews on behavioral and pharmacological interventions in autism. The consensus paper includes current evidence of what interventions have been studied and shown effective, why or why not, and can be found here. Applied Behavioral Analysis ABA works to systematically change behavior based on principles of learning derived from behavioral psychology.
In addition, ABA teaches new skills and applies those skills to new situations. Early Intensive Behavioral Intervention EIBI is a type of ABA for very young children with an ASD, usually younger than five, often younger than three. Pivotal Response Training is a variation of ABA that works to increase a child s motivation to learn, monitor his own behavior, and initiate communication with others by focusing on behaviors that are seen as key to learning other skills, such as language, play, and social skills.
ABA encourages positive behaviors and discourages negative behaviors. Discrete trial teaching is a common form of ABA, in which what is being taught is broken down into smaller steps, and taught using prompts and rewards for each step. Prompts and rewards are phased out over time. The Lovaas Model consists of 20-40 hours of highly structured, discrete trial training, integrating ABA techniques into an early intervention program.
The intervention typically begins when the child is between the ages of 2-8 years old, and no later than 12 years old. Additionally, the use of language and imitation are crucial for the teaching model. Click here to learn more about the Lovaas Model. The Early Start Denver Model is an early intervention program designed for infants, toddlers, and pre-schoolers ages 12-48 months with autism. This training works to generalize skills across many settings with different people.
The technique utilizes child-specific reinforcers to motivate and reward success. Developed by Geraldine Dawson, Ph.and Sally Rogers, Ph.it is the only experimentally verified early-intervention program designed for children with autism as young as 18 months old. ESDM applies the principles of ABA to an early-intervention program. Similar to Pivotal Response Training, interventions are delivered within play-based, relationship-focused routines. Studies testing the efficacy of the treatment have found the intervention resulted in significant improvements in IQ, language, adaptive behavior, and autism diagnosis.
To learn more about the Early Start Denver Model, read more here. Speech Therapy. Speech therapy with a licensed speech-language pathologist helps to improve a person s communication skills, allowing him to better express his needs or wants. For individuals with ASD, speech therapy is often most effective when speech-language pathologists work with teachers, support personnel, families, and the child s peers to promote functional communication in natural settings.
Since people with ASDs have deficits in social communication, speech therapy is an important treatment option. Some individuals with ASD are nonverbal and unable to develop verbal communication skills, and the use of gestures, sign language, and picture communication programs are often useful tools to improve their abilities to communicate. Occupational Therapy OT. Occupational therapy is often used as a treatment for the sensory integration issues associated with ASDs.
It is also used to help teach life skills that involve fine-motor movements, such as dressing, using utensils, cutting with scissors, and writing. OT works to improve the individual s quality of life and ability to participate fully in daily activities. Each occupational therapy program is based on individual evaluations and goals. Occupational therapy for young children with ASD often focuses on improving sensory integration and sensorimotor issues.
In older children, OT often focuses on improving social behavior and increasing independence. Physical Therapy PT. Physical therapy is used to improve gross motor skills and handle sensory integration issues, particularly those involving the individual s ability to feel and be aware of his body in space.
Similar to OT, physical therapy is used to improve the individual s ability to participate in everyday activities. PT works to teach and improve skills such as walking, sitting, coordination, and balance. Physical therapy is most effective when integrated in an early intervention program. Pharmaceutical treatments can help ameliorate some of the behavioral symptoms of ASD, including irritability, aggression, and self-injurious behavior.
Additionally, by medically reducing interfering or disruptive behaviors, other treatments, including ABA, may be more effective. Medications should be prescribed and monitored by a qualified physician. Risperidone is the first FDA-approved medication for the treatment of symptoms associated with of ASD in children and adolescents, including aggressive behavior, deliberate self-injury, and temper tantrums.
Read the studies below. Aripriprazole is also FDA-approved for the treatment of irritability in children and adolescents with ASD. Other Therapies. There are dozens of other therapies that incorporate the practices of evidence based approaches to helping improve symptoms of ASD. A 2009 study published in Pediatrics found that in a group of 98 children, by week 8, 52 of those taking aripriprazole, in the form of Abilify, experienced a 25 or greater reduction in autism-related irritability symptoms compared with 14 of those who took the placebo.
Similar efforts to summarize scientific information on autism interventions have been conducted by the Missouri Guidelines Initiative, which has reported similar findings and can be found here. Researchers have identified these core practices and reported on what they are and the evidence behind them at the National Professional Development Center NPDC on ASD, which can be found here.
The goal of periodically summarizing these practices is to not only identify additional methods, but to communicate to parents, educators, legislators and other community members what is of value. They use stringent criteria on sometimes emerging, new evidence. There are a number of practices that have been incorporated into recreational activities or technological tools. Alternatively, most interventions come in packages that include more than one practice in more than one setting.
Many interventions that have been shown to be effective in the research lab have not moved into community settings, at least yet. When examining the right behavioral intervention for yourself or your child, it is important that the intervention incorporate the practices of effective behavioral interventions, rather than have a name or a specific methodology as discussed in the reference below.
As one example, the music therapies of today represent a way to deliver communication interventions in a social environment, rather than just playing music. In order to see some of these evidence-based practices in action, you can see videos of them at the Autism Focused Intervention Resources and Modules resource of the NPDC on ASD. 2020 Autism Science Foundation 106 West 32nd Street, Suite 182, New York, NY 10001 Autism Science Foundation is a 501 c 3 non-profit organization.
2 Signs and symptoms vary among those affected. Turner syndrome TSalso known 45,Xor 45,X0is a genetic condition in which a female is partly or completely missing an X chromosome. Turner syndrome. 1 Often, a short and webbed neck, low-set ears, low hairline at the back of the neck, short stature, and swollen hands and feet are seen at birth. 1 Typically, they develop menstrual periods and breasts only with hormone treatment, and are unable to have children without reproductive technology.
1 Heart defects, diabetes, and low thyroid hormone occur more frequently. 1 Most people with TS have normal intelligence. 1 Many have troubles with spatial visualization that may be needed for mathematics. 1 Vision and hearing problems occur more often. Turner syndrome Other names Ullrich Turner syndrome; Bonnevie Ullrich Turner syndrome; gonadal dysgenesis; 45X; 45X0 Girl with Turner syndrome before and after an operation for neck-webbing Specialty Pediatrics, medical genetics Symptoms Webbed neck, short stature, swollen hands and feet 1 Complications Heart defects, diabetes, low thyroid hormone 1 Usual onset At birth 1 Duration Long term Causes Missing X chromosome 2 Diagnostic method Physical signs, genetic testing 3 Medication Human growth hormone, estrogen replacement therapy 4 Prognosis Shorter life expectancy 5 Frequency 1 in 2,000 to 5,000 6 7.
Turner syndrome is not usually inherited; rather, it occurs during formation of the reproductive cells in a parent or in early cell division during development. 8 10 Turner syndrome is due to a chromosomal abnormality in which all or part of one of the X chromosomes is missing or altered. 11 While most people have 46 chromosomes, people with TS usually have 45.
8 9 No environmental risks are known, and the mother s age does not play a role. 11 The chromosomal abnormality may be present in just some cells in which case it is known as TS with mosaicism. 5 In these cases, the symptoms are usually fewer and possibly none occur at all. No cure for Turner syndrome is known. 12 Diagnosis is based on physical signs and genetic testing. 4 Human growth hormone injections during childhood may increase adult height. 4 Estrogen replacement therapy can promote development of the breasts and hips.
4 Medical care is often required to manage other health problems with which TS is associated. 4 Treatment may help with symptoms. Turner syndrome occurs in between one in 2,000 6 and one in 5,000 females at birth. 8 Generally people with TS have a shorter life expectancy, mostly due to heart problems and diabetes. 7 All regions of the world and cultures are affected about equally.
5 Henry Turner first described the condition in 1938. 13 In 1964, it was determined to be due to a chromosomal abnormality. 1 Prenatal 1. 2 Cardiovascular 1. 1 Congenital heart disease 1. 1 Bicuspid aortic valve 1. 2 Coarctation of the aorta 1. 3 Partial anomalous venous drainage 1. 2 Aortic dilation, dissection, and rupture 1.
2 Risk factors for aortic rupture 1. 3 Pathogenesis of aortic dissection and rupture 1. 6 Diabetes 1. 7 Cognitive 1. 8 Psychological 1. 9 Reproductive 1. 10 Hearing 2 Cause 2. 2 Postnatal 4 Treatment 5 Epidemiology 6 History 7 See also 8 References 9 Further reading 10 External links. 1 Inheritance 3 Diagnosis 3. 1 Prenatal 3. 3 Skeletal 1. 1 Rate of aortic abnormalities 1.
Of the following common symptoms of Turner syndrome, an individual may have any combination of symptoms and is unlikely to have all symptoms. Short stature Lymphedema swelling of the hands and feet of a newborn Broad chest shield chest and widely spaced nipples Low posterior hairline Low-set ears Reproductive sterility Rudimentary ovaries gonadal streak underdeveloped gonadal structures that later become fibrotic Amenorrhoea, the absence of a menstrual period Increased weight, obesity Shortened metacarpal IV Small fingernails Characteristic facial features Webbed neck from cystic hygroma in infancy Aortic valve stenosis Coarctation of the aorta Bicuspid aortic valve most common cardiac problem Horseshoe kidney Visual impairments sclera, cornea, glaucoma, etc.
Ear infections and hearing loss High waist-to-hip ratio the hips are not much bigger than the waist Attention deficit hyperactivity disorder problems with concentration, memory, attention with hyperactivity seen mostly in childhood and adolescence Nonverbal learning disability problems with maths, social skills, and spatial relations. Other features may include a small lower jaw micrognathiacubitus valgus, 14 soft upturned nails, palmar crease, and drooping eyelids.
Less common are pigmented moles, hearing loss, and a high-arch palate narrow maxilla. While most of the physical findings are harmless, significant medical problems can be associated with the syndrome. Most of these significant conditions are treatable with surgery and medication. Turner syndrome manifests itself differently in each female affected by the condition; therefore, no two individuals share the same features.
Prenatal Edit. Despite the excellent postnatal prognosis, 99 of Turner syndrome conceptions are thought to end in miscarriage or stillbirth, 16 and as many as 15 of all spontaneous abortions have the 45,X karyotype. 17 18 Among cases that are detected by routine amniocentesis or chorionic villus sampling, one study found that the prevalence of Turner syndrome among tested pregnancies was 5. 3 times higher, respectively, than among live neonates in a similar population. Cardiovascular Edit.
21 The variations found in the different studies are mainly attributable to variations in noninvasive methods used for screening and the types of lesions that they can characterize. 22 However, 23 it could be simply attributable to the small number of subjects in most studies. Two studies found a rate of cardiovascular malformations of 30 24 and 38 25 in a group of pure 45,X monosomy. Considering other karyotype groups, though, they reported a prevalence of 24.
3 24 and 11 25 in people with mosaic X monosomy, and a rate of 11 in people with X chromosomal structural abnormalities. The higher rate in the group of pure 45,X monosomy is primarily due to a difference in the rate of aortic valve abnormalities and coarctation of the aorta, the two most common cardiovascular malformations. Congenital heart disease Edit. The most commonly observed are congenital obstructive lesions of the left side of the heart, leading to reduced flow on this side of the heart.
This includes bicuspid aortic valve and coarctation narrowing of the aorta. The rate of cardiovascular malformations among patients with Turner syndrome ranges from 17 20 to 45. More than 50 of the cardiovascular malformations of individuals with Turner syndrome in one study were bicuspid aortic valves or coarctation of the aorta usually preductalalone or in combination.
Other congenital cardiovascular malformations, such as partial anomalous venous drainage and aortic valve stenosis or aortic regurgitation, are also more common in Turner syndrome than in the general population. Hypoplastic left heart syndrome represents the most severe reduction in left-sided structures. Bicuspid aortic valve Edit. Up to 15 of adults with Turner syndrome have bicuspid aortic valves, meaning only two, instead of three, parts to the valves in the main blood vessel leading from the heart are present.
Since bicuspid valves are capable of regulating blood flow properly, this condition may go undetected without regular screening. However, bicuspid valves are more likely to deteriorate and later fail. Calcification also occurs in the valves, 26 which may lead iq option é seguro a progressive valvular dysfunction as evidenced by aortic stenosis or regurgitation. With a rate from 12.
5 Dawson-Falk et al.1992bicuspid aortic valve is the most common congenital malformation affecting the heart in this syndrome. It is usually isolated, but it may be seen in combination with other anomalies, particularly coarctation of the aorta. Coarctation of the aorta Edit. Between 5 and 10 of those born with Turner syndrome have coarctation of the aorta, a congenital narrowing of the descending aorta, usually just distal to the origin of the left subclavian artery the artery that branches off the arch of the aorta to the left arm and opposite to the ductus arteriosus termed juxtaductal.
Estimates of the prevalence of this malformation in patients with Turner syndrome range from 6. A coarctation of the aorta in a female is suggestive of Turner syndrome and suggests the need for further tests, such as a karyotype. Partial anomalous venous drainage Edit. This abnormality is a relatively rare congenital heart disease in the general population. The prevalence of this abnormality also is low around 2. 9 in Turner syndrome.
However, its relative risk is 320 in comparison with the general population. Different karyotypes may have differing rates of cardiovascular malformations. In a patient with Turner syndrome, these left-sided cardiovascular malformations can result in an increased susceptibility to bacterial endocarditis. Therefore, prophylactic antibiotics should be considered when procedures with a high risk of endocarditis are performed, such as dental cleaning.
Turner syndrome is often associated with persistent hypertension, sometimes in childhood. In the majority of Turner syndrome patients with hypertension, no specific cause is known. In the remainder, it is usually associated with cardiovascular or kidney abnormalities, including coarctation of the aorta. Aortic dilation, dissection, and rupture Edit.
Two studies have suggested aortic dilatation in Turner syndrome, typically involving the root of the ascending aorta and occasionally extending through the aortic arch to the descending aorta, or at the site of previous coarctation of the aorta repair. A study that evaluated 28 girls with Turner syndrome found a greater mean aortic root diameter in people with Turner syndrome than in the control group matched for body surface area.
Nonetheless, the aortic root diameters found in Turner syndrome patients were still well within the limits. 30 Iq option é seguro has been confirmed by a study that evaluated 40 patients with Turner syndrome. 21 The study presented basically the same findings a greater mean aortic root diameter, which nevertheless remains within the normal range for body surface area.
Whether aortic root diameters that are relatively large for body surface area but still well within normal limits imply a risk for progressive dilatation remains unproven. Rate of aortic abnormalities Edit. The prevalence of aortic root dilatation ranges from 8. 8 29 to 42 27 in iq option é seguro with Turner syndrome. Even if not every aortic root dilatation necessarily goes on to an aortic dissection circumferential or transverse tear of the intimacomplications such as dissection, aortic rupture resulting in death may occur.
The natural history of aortic root dilatation is still unknown, but it is linked to aortic dissection and rupture, which has a high mortality rate. Aortic dissection affects 1 to 2 of patients with Turner syndrome. As a result, any aortic root dilatation should be seriously taken into account, as it could become a fatal aortic dissection. Routine surveillance is highly recommended. Risk factors for aortic rupture Edit. Cardiovascular malformations typically bicuspid aortic valve, coarctation of the aorta, and some other left-sided cardiac malformations and hypertension predispose to aortic dilatation and dissection in the general population.
Indeed, these same risk factors are found in more than 90 of patients with Turner syndrome who develop aortic dilatation. Only a small number of patients around 10 have no apparent predisposing risk factors. The risk of hypertension is increased three-fold in patients with Turner syndrome. Because of its relation to aortic dissection, blood pressure must be regularly monitored and hypertension should be treated aggressively with an aim to keep blood pressure below 140 80 mmHg.
As with the other cardiovascular malformations, complications of aortic dilatation is commonly associated with 45,X karyotype. Pathogenesis of aortic dissection and rupture Edit. The exact role that these risk factors play in the process leading to rupture is unclear. Aortic root dilatation is thought to be due to a mesenchymal defect as pathological evidence of cystic medial necrosis has been found by several studies. The association between a similar defect and aortic dilatation is well established in such conditions such as Marfan syndrome.
Also, abnormalities in other mesenchymal tissues bone matrix and lymphatic vessels suggests a similar primary mesenchymal defect in patients with Turner syndrome. 29 However, no evidence suggests that patients with Turner syndrome have a significantly higher risk of aortic dilatation and dissection in absence of predisposing factors. So, the risk of aortic dissection in Turner syndrome appears to be a consequence of structural cardiovascular malformations and hemodynamic risk factors rather than a reflection of an inherent abnormality in connective tissue.
Strangely, Turner syndrome seems to be associated with unusual forms of partial anomalous venous drainage. The natural history of aortic root dilatation is unknown, but because of its lethal potential, this aortic abnormality needs to be carefully followed. Skeletal Edit. Normal skeletal development is inhibited due to a large variety of factors, mostly hormonal.
The average height of a woman with Turner syndrome, in the absence of growth hormone treatment, is 4 ft 7 in 140 cm. Women with Turner s mosaicism can reach normal average height. The fourth metacarpal bone fourth toe and ring finger may be unusually short, as may the fifth. Due to inadequate production of estrogen, many of those with Turner syndrome develop osteoporosis.
This can decrease height further, as well as exacerbate the curvature of the spine, possibly leading to scoliosis. It is also associated with an increased risk of bone fractures. Kidney Edit. About one-third of all women with Turner syndrome have one of three kidney abnormalities. A single, horseshoe-shaped kidney on one side of the body An abnormal urine-collecting system Poor blood flow to the kidneys.
Even with these abnormalities, the kidneys of most women with Turner syndrome function normally. Some of these conditions can be corrected surgically. However, as noted above, kidney problems may be associated with hypertension. Thyroid Edit. Approximately one-third of all women with Turner syndrome have a thyroid disorder. 27 Usually it is hypothyroidism, specifically Hashimoto s thyroiditis. Diabetes Edit. If detected, it can be easily treated with thyroid hormone supplements.
Women with Turner syndrome are at a moderately increased risk of developing type 1 diabetes in childhood and a substantially increased risk of developing type 2 diabetes by adult years. The risk of developing type 2 diabetes can be substantially reduced by maintaining a healthy weight. Cognitive Edit. People with Turner syndrome have normal intelligence, and demonstrate relative strengths in verbal skills, but may exhibit weaker nonverbal skills particularly in arithmetic, select visuospatial skills, and processing speed.
32 Turner syndrome does not typically cause intellectual disability or impair cognition. However, learning difficulties are common among women with Turner syndrome, particularly a specific difficulty in perceiving spatial relationships, such as nonverbal learning disorder. This may also manifest itself as a difficulty with motor control or with mathematics.
33 While it is not correctable, in most cases it does not cause difficulty in daily living. Most Turner syndrome patients are employed as adults and lead productive lives. Also, a rare variety of Turner syndrome, known as Ring-X Turner syndromehas about a 60 association with intellectual disability clarification needed. This variety accounts for around 2 4 of all Turner syndrome cases. Psychological Edit.
Social difficulties appear to be an area of vulnerability for young women. 35 Counseling affected individuals and their families about the need to carefully develop social skills and relationships may prove useful in advancing social adaptation. Women with Turner syndrome may experience adverse psychosocial outcomes which can be improved through early intervention and the provision of appropriate psychological and psychiatric care.
Genetic, hormonal, and medical problems associated with TS are likely to affect psychosexual development of female adolescent patients, and thus influence their psychological functioning, behavior patterns, social interactions, and learning ability. Although TS constitutes a chronic medical condition, with possible physical, social, and psychological complications in a woman s life, hormonal and estrogen replacement therapy, and assisted reproduction, are treatments that can be helpful for TS patients and improve their quality of life.
Women with Turner syndrome are almost universally infertile. Reproductive Edit. 38 39 Even when such pregnancies do occur, there is a higher than average risk of miscarriage or birth defects, including Turner syndrome or Down syndrome. While some women with Turner syndrome have successfully become pregnant and carried their pregnancies to term, this is very rare and is generally limited to those women whose karyotypes are not 45,X. 36 Research shows a possible association between age at diagnosis and increased substance use and depressive symptoms.
40 Some women with Turner syndrome who are unable to conceive without medical intervention may be able to use IVF or other fertility treatments. Usually, estrogen replacement therapy is used to spur the growth of secondary sexual characteristics at the time when puberty should onset. While very few women with Turner syndrome menstruate spontaneously, estrogen therapy requires a regular shedding of the uterine lining withdrawal bleeding to prevent its overgrowth.
Withdrawal bleeding can be induced monthly, like menstruation, or less often, usually every three months, if the patient desires. Estrogen therapy does not make a woman with nonfunctional ovaries fertile, but it plays an important role in assisted reproduction; the health of the uterus must be maintained with estrogen if an eligible woman with Turner Syndrome wishes to use IVF using donated oocytes. 45,X 46,XY due to the risk of development of ovarian malignancy most common is gonadoblastoma gonadectomy is recommended.
Especially in mosaic cases of Turner syndrome that contains Y-chromosome e. 27 42 Turner syndrome is characterized by primary amenorrhoea, premature ovarian failure hypergonadotropic hypogonadismstreak gonads and infertility however, technology especially oocyte donation provides the opportunity of pregnancy in these patients. Failure to develop secondary sex characteristics sexual infantilism is typical. As more women with Turner syndrome complete pregnancy thanks to modern techniques to treat infertility, it has to be noted that pregnancy may be a risk of cardiovascular complications for the mother.
Indeed, several studies had suggested an increased risk for aortic dissection in pregnancy. It seems that the high risk of aortic iq option é seguro during pregnancy in women with Turner syndrome may be due to the increased hemodynamic load rather than the high estrogen rate. 27 Of course, these findings are important and need to be remembered while following a pregnant patient with Turner syndrome. Hearing Edit.
Recurrent acute otitis media AOM and otitis media with effusion OME commonly occur in children with Turner syndrome during the preschool age, which can persist or develop later in childhood. The recurring AOM can also be a predisposition to cholesteatomas. 43 44 People with the monosomy 45, X karyotype have an increased rate of hearing loss over other TS karyotype variants. Conductive hearing losses are more commonly seen with children than adults and becomes more of a sensorineural pattern once in the adolescence age.
There seems to be an apparent linear relation between hearing loss and age in TS. 45 46 About 75 of people with Turner syndrome have some hearing loss, with the most common presenting as a high frequency sensorineural hearing loss HFSNHL across all ages. 29 The influence of estrogen has been examined but remains unclear.
47 48 49 People with TS tend to have more of a progressive hearing loss with a higher decline rate than those in their corresponding age groups with hearing loss. The increased decline tends to occur in the higher frequency range, with a rate of around 0. Turner syndrome is caused by the absence of one complete or partial copy of the X chromosome in some or all the cells. The abnormal cells may have only one X monosomy 45,X or they may be affected by one of several types of partial monosomy like a deletion of the short p arm of one X chromosome 46,X,del Xp or the presence of an isochromosome with two q arms 46,X,i Xq 51 Turner syndrome has distinct features due to the lack of pseudoautosomal regions, which are typically spared from X-inactivation.
5 In mosaic individuals, cells with X monosomy 45,X may occur along with cells that are normal 46,XXcells that have partial monosomies, or cells that have a Y chromosome 46,XY. 51 The presence of mosaicism is estimated to be relatively common in affected individuals 67 90. Inheritance Edit. In the majority of cases where monosomy occurs, the X chromosome comes from the mother. 52 This may be due to a nondisjunction in the father. Meiotic errors that lead to the production of X with p arm deletions or abnormal Y chromosomes are also mostly found in the father.
53 Isochromosome X or ring chromosome X on the other hand are formed equally often by both parents. 53 Overall, the functional X chromosome usually comes from the mother. In most cases, Turner syndrome is a sporadic event, and for the parents of an individual with Turner syndrome the risk of recurrence is not increased for subsequent pregnancies.
Rare exceptions may include the presence of a balanced translocation of the X chromosome in a parent, or where the mother has 45,X mosaicism restricted to her germ cells. Turner syndrome may be diagnosed by amniocentesis or chorionic villus sampling during pregnancy.heart defect, kidney abnormality, cystic hygroma, ascites. Usually, fetuses with Turner syndrome can be identified by abnormal ultrasound findings i.
In a study of 19 European registries, 67. 2 of prenatally diagnosed cases of Turner syndrome were detected by abnormalities on ultrasound. 1 of cases had one anomaly present, and 30. 9 had two or more anomalies. An increased risk of Turner syndrome may also be indicated by abnormal triple or quadruple maternal serum screen. The fetuses diagnosed through positive maternal serum screening are more often found to have a mosaic karyotype than those diagnosed based on ultrasonographic abnormalities, and conversely, those with mosaic karyotypes are less likely to have associated ultrasound abnormalities.
Postnatal Edit. Turner syndrome can be diagnosed postnatally at any age. Often, it is diagnosed at birth due to heart problems, an unusually wide neck or swelling of the hands and feet. However, it is also common for it to go undiagnosed for several years, often until the girl reaches the age of puberty and fails to develop typically the changes associated with puberty do not occur.
In childhood, a short stature can be indicative of Turner syndrome. A test called a karyotype, also known as a chromosome analysis, analyzes the chromosomal composition of the individual. This is the test of choice to diagnose Turner syndrome. As a chromosomal condition, there is no cure for Turner syndrome. However, much can be done to minimize the symptoms. For example 57. Growth hormone, either alone or with a low dose of androgen, will increase growth and probably final adult height.
Growth hormone is approved by the U. Food and Drug Administration for treatment of Turner syndrome and is covered by many insurance plans. 57 58 There is evidence that this is effective, even in toddlers. 59 Estrogen replacement therapy such as the birth control pill, has been used since the condition was described in 1938 to promote development of secondary sexual characteristics. 57 Women with Turner syndrome who do not have spontaneous puberty and who are not treated with estrogen are at high risk for osteoporosis and heart conditions.
Estrogens are crucial for maintaining good bone integrity, cardiovascular health and tissue health. Modern reproductive technologies have also been used to help women with Turner syndrome become pregnant if they desire. For example, a donor egg can be used to create an embryo, which is carried by the Turner syndrome woman. 57 Uterine maturity is positively associated with years of estrogen use, history of spontaneous menarche, and negatively associated with the lack of current hormone replacement therapy.
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