S A M M Y C A S E S . C A S E @ W A R W I C K . A C . U KM A T T V R E U G D E M . V R E U G D E @ W A R W I C K . A C . U K

PUBERTY

GnRH

Granulosa Cells

Oestradiol

Aromatase

FSH

LH

FSH

LH

Theca Cells

Androgens

FEMALES MALES

Testosterone

Oestradiol

Inhibin

Sertoli Cells

Leydig Cells

HOW DO WE STAGE PUBERTY?

Tanner Stages!What are the 5 Tanner stages of breast development?1. No palpable glandular tissue, areola not pigmented2. Glandular tissue palpable. Nipple and areola project as single mound - breast bud3. Increased glandular tissue, breasts enlarge, increased size areola, contours breast and areola remain in a single plane4. Further breast enlargement, increased pigmentation areola. Areola and nipple form a secondary mound above the breast5. Mature form. Areola and nipple no longer project from the breast

WHAT CHANGES OCCUR IN MALES DURING PUBERTY DUE TO THE EFFECTS OF

TESTOSTERONE? (6)

1. External genitalia growth.2. Hair growth. 3. Linear growth. 4. Accessory sex organs. Prostate palpable and seminal vesicles develop secretory activity5. Deepening voice. 6. Psyche - More aggressive, increased libido, sexual potential develops.

WHAT CHANGES OCCUR IN FEMALES DURING PUBERTY DUE TO THE EFFECTS OF

OESTROGEN? (5)

1. External genitalia growth2. Hair growth3. Linear growth4. Breast development5. Menstruation

WHAT FACTORS CAN DELAY WHEN PUBERTY BEGINS? (7)

1. Malnutrition -  an adequate body fat content is required for the hypothalamus to begin signalling

2. Chronic diseases e.g. renal failure, CCF, Crohn’s3. Low BMI4. Exercise in females- athletes, ballerinas5. Endocrine - thyroid, adrenal 6. Genetic factors - white girls have a delayed

puberty compared to black7. Emotional Deprivation

HOW CAN WE ANALYSE PUBERTY USING BONE AGE?

• X-ray of left wrist (most people are right-handed and this will have developed more due to use)• Compare skeletal age with chronologic age• Used in conjunction with clinical information to

evaluate and treat growth and puberty disorders

WHAT IS PRECOCIOUS PUBERTY?

Puberty with an onset before 8 years in girls or 9 years in boysCan be a variation of normal development or due to a brain tumour or injury Only treated if we need to prevent very short stature (although consider psychological impact)

WHAT IS CONSTITUTIONAL DELAYED ADOLESCENCE AND HOW DO YOU TREAT IT?

• No growth disorder is present but the young person is at the far end of the spectrum compared to peers in terms of growth.• Treatment = Short-term low-dose of sex steroid

treatment

WHAT IS HYPERGONADOTROPIC HYPOGONADISM? GIVE SOME EXAMPLES AND TREATMENT

Also known as primary hypogonadism (diminished functional activity of the gonads)A condition which is characterized by hypogonadism due to an impaired response of the gonads to FSH and LH, and in turn a lack of sex steroid production and elevated gonadotropin levels (as an attempt of compensation by the body).Examples = Turner’s Syndrome, Kleinefelter’s syndromeTreatment = sex steroid replacement

WHAT IS HYPOGONADOTROPIC HYPOGONADISM? GIVE SOME EXAMPLES AND TREATMENT

Also known as secondary hypogonadismA condition which is characterized by hypogonadism due to an impaired secretion of FSH and LH, by the pituitary gland in the brain, and in turn decreased gonadotropin levels and a resultant lack of sex steroid production.Examples = Brain tumours, congenital hypothalamic deficiencyTreatment = Sex steroid replacement, GnRH administration

PINK REVISION (YAY…)

Block 1:What are the key components of person-centred care? (6)Seeing (and getting to know) the patient as a person rather than the person as a patient. Putting the person’s needs and preferences, as they define them, first and above those as identified by clinicians. Shared decision making. Recognising the person’s strengths in self-care and management of their condition. All interactions and care underpinned by values of compassion, dignity and respect. Patient and public involvement in the design and delivery of services.

PINK REVISION (YAY…)

Block 2:Describe the main models of doctor-patient relationships and their key featuresPaternalistic model - Dr makes a systematic enquiry: asks specific questions. Patient is passive; answers the doctor’s questions. Information flow: largely from doctor to patient, often minimal information given. Doctor makes the decision about what is best for the patient: underlying assumption is that the doctors is best placed to make the decision regarding treatment. Expectation that patient will agree as ‘doctor knows best’. Shared Model - Two way exchange of information between patient and doctor at all stages. Both participants are seen as bringing expertise. Informed Model - Doctor communicates all relevant information and treatment options, and the risk and benefits, to patient. Decision making is sole prerogative of the patient.

PINK REVISION (YAY…)

Block 3:What are the 9 Bradford Hill criteria for causality?Analogy - link likely if a similarity exists with other diseasesBiological plausibilityConsistency of association -observed in different studies and subgroupsCoherence of theory - conforms with current knowledgeDose response - different levels of exposure lead to different risksReversibility - removal of factor leads to reduced riskStrength of associationSpecificity of association - disease associated with 1 specific factor Temporality -exposure precedes outcome.

PINK REVISION (YAY…)

Block 4:What does a funnel plot show and how do you interpret them?Shows publication bias - Studies with positive results are more likely to be published than negative studies. The subsequent over-representation of positive studies in systematic reviews may mean that reviews are biased toward a positive result. If publication bias is present, funnel plots will often be asymmetrical and skewed. If it isn't present the plot will show an inverted V and be symmetrical.

PINK REVISION (YAY…)

Block 5:What must a minor demonstrate in order to be deemed Gillick Competent?A sufficient understanding and intelligence to be capable in making up his mind on the matter requiring decision AND ALSO a sufficient maturity to understand what is involved