1. SAMMY CASE S.CASE@WARWICK.AC.UKS.CASE@WARWICK.AC.UK MATT VREUGDE M.VREUGDE@WARWICK.AC.UKM.VREUGDE@WARWICK.AC.UK PUBERTY

2. GnRH Granulosa Cells Oestradiol Aromatase FSH LH FSH LH Theca Cells Androgens FEMALES MALES Testosterone Oestradiol Inhibin Sertoli Cells Leydig Cells

3. HOW DO WE STAGE PUBERTY? Tanner Stages! What are the 5 Tanner stages of breast development? 1. No palpable glandular tissue, areola not pigmented 2. Glandular tissue palpable. Nipple and areola project as single mound - breast bud 3. Increased glandular tissue, breasts enlarge, increased size areola, contours breast and areola remain in a single plane 4. Further breast enlargement, increased pigmentation areola. Areola and nipple form a secondary mound above the breast 5. Mature form. Areola and nipple no longer project from the breast

5. 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 activity 5. Deepening voice. 6. Psyche - More aggressive, increased libido, sexual potential develops.

6. WHAT CHANGES OCCUR IN FEMALES DURING PUBERTY DUE TO THE EFFECTS OF OESTROGEN? (5) 1. External genitalia growth 2. Hair growth 3. Linear growth 4. Breast development 5. Menstruation

7. 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’s 3.Low BMI 4.Exercise in females- athletes, ballerinas 5.Endocrine - thyroid, adrenal 6.Genetic factors - white girls have a delayed puberty compared to black 7.Emotional Deprivation

8. 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

9. WHAT IS PRECOCIOUS PUBERTY? Puberty with an onset before 8 years in girls or 9 years in boys Can 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)

10. 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

11. 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 syndrome Treatment = sex steroid replacement

12. WHAT IS HYPOGONADOTROPIC HYPOGONADISM? GIVE SOME EXAMPLES AND TREATMENT Also known as secondary hypogonadism A 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 deficiency Treatment = Sex steroid replacement, GnRH administration

13. 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.

14. PINK REVISION (YAY…) Block 2: Describe the main models of doctor-patient relationships and their key features Paternalistic 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.

15. PINK REVISION (YAY…) Block 3: What are the 9 Bradford Hill criteria for causality? Analogy - link likely if a similarity exists with other diseases Biological plausibility Consistency of association -observed in different studies and subgroups Coherence of theory - conforms with current knowledge Dose response - different levels of exposure lead to different risks Reversibility - removal of factor leads to reduced risk Strength of association Specificity of association - disease associated with 1 specific factor Temporality -exposure precedes outcome.

16. 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.

17. 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