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Received: 26 November 2019 Revised: 10 January 2020 Accepted: 19 January 2020 DOI: 10.1111/obr.13005 PEDIATRICS/PHYSIOLOGY Adipokines: A gear shift in puberty DesirĂ©e Nieuwenhuis | NatĂ lia Pujol-Gualdo Amanda J. Kiliaan Department of Anatomy, Radboud university medical center, Donders Institute for Brain, Cognition and Behaviour, Preclinical Imaging Center PRIME, Nijmegen, The Netherlands Correspondence Amanda J. Kiliaan, PhD, Associate Professor, Department of Anatomy, Donders Institute for Brain, Cognition, and Behaviour, Preclinical Imaging Center PRIME, Radboud university medical center, 6500 HB Nijmegen, Geert Grooteplein 21N 6525 EZ Nijmegen, The Netherlands. Email: amanda.kiliaan@radboudumc.nl Funding information Europees Fonds voor Regionale Ontwikkeling (EFRO), Grant/Award Number: BriteN 2016 1 | INTRODUCTION The prevalence of obesity in adolescents and children is increasing in | Ilse A.C. Arnoldussen | Summary In this review, we discuss the role of adipokines in the onset of puberty in children with obesity during adrenarche and gonadarche and provide a clear and detailed overview of the biological processes of two major players, leptin and adiponectin. Adipokines, especially leptin and adiponectin, seem to induce an early onset of puberty in girls and boys with obesity by affecting the hypothalamic-pituitary- gonadal (HPG) axis. Moreover, adipokines and their receptors are expressed in the gonads, suggesting a role in sexual maturation and reproduction. All in all, adipokines may be a clue in understanding mechanisms underlying the onset of puberty in child- hood obesity and puberty onset variability. KEYWORDS adipokines, obesity, puberty 1,2 the age of 5 years were overweight or were with obesity in 2016, and 3 Obesity is defined by an excessive accumulation of white adipose tissue (WAT), and it is often indicated by a body mass index (BMI) 4 above 30. Two main types of adipose tissue were described: WAT and brown adipose tissue (BAT), which differ in morphology and func- 5-7 Ilse A.C. Arnoldussen and Amanda J. Kiliaan contributed equally to this work. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation Obesity Reviews. 2020;21:e13005. wileyonlinelibrary.com/journal/obr 1 of 10 https://doi.org/10.1111/obr.13005 alarming rates. Specifically, worldwide, 41 million children below this number is expected to increase to 70 million in 2025. obesity is associated with various severe health complications, includ- ing increased risk of diabetes mellitus type 2, hypertension, heart dis- eases, and disturbances in sex hormone levels. 5,6 and mitochondria and plays a role in thermogenesis. Adipocytes in tion. BAT consists of adipocytes containing multiple lipid droplets WAT contain only a few mitochondria and a single lipid droplet. Adipose tissue has several functions including the storage of energy, thermogenesis, and the production and secretion of adipokines Generally, two physiological processes, adrenarche and gonadarche, 11,24 Childhood 5,7,8 a key role in puberty onset. Puberty is known as a period through which the body changes physically, being a physiological process resulting in the maturation of children, i.e. they develop sexual characteristics and obtain reproduc- 9,11 Adipokines are involved in a number of physiological processes including blood pressure, metabo- lism, glucose, and vascular homeostasis and may play amongst others 8-10 (hormones, cytokines, and peptides). tive functions. between obesity and puberty,2,12-23 the biological mechanisms under- lying obesity and puberty onset remain unclear. Hereafter, we review in detail the role of adipokines in the onset of puberty in childhood obesity. Although many studies have shown associations 2 | INITIATION OF PUBERTY PHYSIOLOGICAL PROCESSES IN THE interact to regulate the onset of puberty. During adrenarche, the adrenal cortex secretes steroid hormones (including 2 of 10 NIEUWENHUIS ET AL. androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, and cortisol), insulin-like growth factor, and growth hormone, which contribute to the pubertal insights on new genetic loci (e.g. melanocortin-4 receptor, mitochon- drial carrier 2, and mitogen-activated protein kinase 13) and on sev- eral pathways that regulate the timing of puberty; however, it partly 34 9,24,25 Both adrenarche and gonadarche are involved in the development growth spurt, body odor, skin oiliness, and skeletal maturation. explains puberty timing variation. Thereby, defining the role of 25 adipokines is of importance in elucidating the variability in puberty as the expression of adipokines is sex-specific and is altered with body composition, adiposity, and during growth spurts. Moreover, adipokines and their receptors are expressed in gonads and several brain regions suggesting involvement in the onset of puberty and sex- ual maturation. Lastly, adipokines interfere in processes regulating timing and duration of puberty, for instance in the HPA and HPG axes which are both key players during adrenarche and gonadarche. Involvement of adipokines in the onset of puberty and specifically in individuals with obesity will be further reviewed in the next 2,24 3 | Puberty onset in girls is assessed using different markers, such as thelarche (breast development), menarche (the start of of pubic hair. pituitary-gonadal (HPG) axis is activated,2,26 and several hormones have been identified to participate in the activation of the HPG axis During gonadarche (Figure 1), the hypothalamic- 2,27 Kisspeptin, neurokinin B, and dynorphin are released by specialized including kisspeptin, neurokinin B, dynorphin, leptin, and ghrelin. 28 key regulator of the pulsatile secretion of gonadotropin releasing neurons, the KNDy neurons in the hypothalamus. Kisspeptin is a 29,30 B stimulates, and dynorphin inhibits the release of kisspeptin, which hormone (GnRH) from the hypothalamus. In addition, neurokinin implies that both coordinate a pulsatile release of kisspeptin. 31 Sub- sections. sequently, the activated HPG axis induces the pituitary gland to secrete luteinising hormone (LH) and follicle stimulating hormone (FSH). As a result, gametogenesis occurs, and the gonads will release sex hormones. Consequently, secondary sex characteristics develop including breast development in girls and an increased testicular vol- 2,26,32 is possibly due to differences in levels of body fat, hypothalamic-pitui- THE ONSET OF PUBERTY IN GIRLS ume in boys. The age at puberty onset varies greatly among individuals, which 19 35 menstruation), and pubic hair development. 33 genome-wide association studies have provided important new tary-adrenal (HPA) axis activity, and genetic background. Recent The average age of However, this age differs between cultures and ethnicities, and since 1980, age at menarche is girls at start of menarche is 12.4 years. 36 significantly decreasing. 36-39 F I G U R E 1 Hormonal regulation in the initiation of puberty in boys and girls. The secretion of kisspeptin, neurokinin B, and dynorphin from KNDy neurons initiate the release of gonadotropin releasing hormone (GnRH) from the hypothalamus. This activates the pituitary gland to produce and secrete luteinising hormone (LH) and follicle stimulating hormone (FSH), which in turn stimulate the gonads to produce estrogen and testosterone in girls and boys, respectively 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License NIEUWENHUIS ET AL. 3 of 10 T A B L E 1 Summary of included studies Authors Year Country Study Design Primary Outcome Sex Sample Size (n) Age (y) Data Collection Lian et al21 2019 China Cross-sectional Puberty starts earlier in Chinese Han girls with obesity compared with Chinese Han girls with normal weight. Girls 2996 9-19 2012 and 2013 Biro et al12 Lazzeri et al20 2018 USA 2018 Italy Longitudinal Cross-sectional Body mass index had a greater effect on age at menarche than did race and ethnicity. Girls 946 6-16 2004-2014 Li et al23 2018 China Longitudinal For both, boys and girls, a higher BMI (ie, overweight and obese) is associated with earlier onset of puberty Girls Girls Boys Girls 542 Deng et al22 Flom et al15 2017 China Cross-sectional Increased BMI is associated with early timing spermarche and menarche. Boys Girls Girls 1278258 9-15 2005-2012 He et al24 Holmgren et al17 2017 China 2017 Sweden Cross-sectional Longitudinal Onset of puberty is not related to obesity in boys. Boys Boys Girls Girls 782 7-17 972 929 5839 Kelly et al19 2017 UK 2016 Brazil 2016 USA Longitudinal prospective cohort Higher BMI in girls is associated with the onset of menstruation at an earlier age. 11 10-18 11-17 Barcellos Gemelli et al25 Cross-sectional Longitudinal Excess weight is associated with early age of menarche. Girls 727 2014 2003-2009 Glass et al16 Lee et al26 In girls, but not in boys, greater adiposity is associated with the earlier onset of puberty. Boys Girls 135 Cabrera et al27 Leonibus et al14 2014 USA 2013 Italy Cross-sectional Longitudinal Thelarche occurred earlier than recently reported, while age of menarche remained unchanged. Girls 610 3-17.9 2007 2005-2012 Currie et al13 2012 Europe, USA, Canada Cross-sectional Overweight/obesity during childhood predicts the early onset of puberty in girls. Girls 20410 11, 13, 15 2005-2006 2017 USA Prospective birth cohort Overweight/obese status at the age of 7 ye was associated with increased risk of early menarche 788 From birth to menarche occurred Pregnancies 1959-1966 2016 USA Cross-sectional Boys with overweight enter puberty earlier compared with boys with normal weight or obesity, while puberty starts later in boys with obesity compared with boys with normal weight and overweight. Boys 3872 6-16 2005-2010 Overweight during childhood shows a relation with the early onset of puberty in girls. 6535 4259 695 11 15 5.8-12.2 2009/2010 2013/2014 2014-2017 Higher BMI during childhood is associated with early puberty. 2008 and 2009 2000-2002 Obesity during childhood is related to the earlier onset of puberty. Boys Girls 84 123 71 (Continues) 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4 of 10 NIEUWENHUIS ET AL. 3.1 | Fat storage For the initiation of puberty, the timing of stimulation and/or inhibi- tion of different hormones is important, and additionally, a certain amount and distribution of body fat is needed in order to start menar- che, which emphasizes the importance of body fat. From an evolution- ary point of view, body fat increases in mammalian females during puberty onset, and it highlights the need to guarantee a healthy preg- 40 women with anorexia nervosa. particularly body fat localized predominantly on the gluteofemoral fat depots, is profoundly associated with start of menarche, more than nancy, offspring, and maternal survival. fat, sex-hormones, and neuroendocrine alterations can evolve in men- strual dysfunction, for instance, in women with severe obesity or in 41-43 44-46 to gluteofemoral fat depots suggesting that leptin may convey infor- amount of total body fat. mation on body fat distribution to the hypothalamus during puberty. An improper level of body Importantly, body fat distribution, Blood leptin levels are strongly related 45 3.2 | HPG axis The HPG axis is activated by the release of kisspeptin resulting in the release of GnRH from the hypothalamus, and LH and FSH from the pituitary gland. In girls, FSH is involved in the development of the folli- cles in the ovaries, and it promotes the secretion of estrogen. LH stim- ulates the production of androgen hormones and induces ovulation 48 9,47 the release of kisspeptin and neurokinin B, and kisspeptin thereby (Figure 1). The secretion of estrogen has an inhibitory effect on inhibits the GnRH release from the hypothalamus. pattern of GnRH is important for the regulation of the menstrual cycle. This roughly 28-day-cycle comprises several phases, including the follicular phase and luteal phase. During the follicular phase, increasing levels of FSH stimulate the maturation of follicles and the production of estrogen from the ovaries. This in turn inhibits the release of FSH from the pituitary gland. A high level of estrogen will induce the production of LH by the pituitary gland, resulting in ovula- tion. The matured follicle secretes progesterone thereby inhibiting the release of GnRH. When the corpus luteum is demolished, there is less 48 3.3 | Adipokines According to results from studies reported in Table 1, girls with obe- sity enter puberty earlier compared with girls with normal higher leptin concentrations inhibit the intake of food and increases inhibition of GnRH. As a consequence, the cycle will start again. whole process, starting from the activated HPG axis, results in the development of the secondary sex characteristics in girls including 9,47 thelarche and menarche. 13,14,16-23,49-51 weight. these girls might be found in the secretion of adipokines. For instance, leptin is positively associated with the amount of body fat. Generally, energy expenditure. 9,52-54 An explanation for the early onset of puberty in The expression This TABLE 1 (Continued) Authors Year Country Study Design Primary Outcome Sample Sex Size (n) Age (y) Data Collection Herman-Giddens et al28 2012 USA Cross-sectional Observed mean ages of beginning genital and pubic hair growth and early testicular volumes were earlier than in past studies, depending on the characteristic and race/ethnicity. Boys 4131 6-16 2005-2010 Sorensen et al29 Aksglaede et al30 2010 2009 Denmark Denmark Cross-sectional/longitudinal Longitudinal Puberty onset at earlier ages was associated with an increased BMI in boys. Boys 1528 5.8-19.9 1991-1993/2006-2008 1930-1969 Juul et al31 Ribeiro et al32 2007 2006 Denmark Portugal Retrospective cohort Cross-sectional Higher BMI is associated with early voice break. 11-15 10-15 1990-1999 Kaplowitz et al18 Abbreviation: BMI, body mass USA Cross-sectional The early onset of puberty in Caucasian girls is likely related to an increased BMI. 5-12 1992-1993 2001 index. The higher BMI in boys and girls at 7 y of age, the earlier they enter puberty. Boys 21 612 Girls 135 223 Boys 463 Boys 382 Girls 437 Girls 10 750 Early sexual maturation in boys and girls is associated with overweight. 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License NIEUWENHUIS ET AL. 5 of 10 Leptin may possibly play a role in adrenarche as its plasma level increases with higher levels of body fat and as it can modulate both girls. 33 ing adrenarche. In coherence, in children with obesity, the androgen These findings suggested that lower reproductive status was associated with higher total adiponectin concentrations and that a higher reproductive status was related to higher HMW adiponectin the HPA and HPG axes. These axes are functionally integrated dur- DHEAS was positively associated with leptin levels. Nevertheless, concentrations in girls. In addition, individuals with obesity often another study showed that enhanced adrenal androgen secretion in girls with premature adrenarche was not explained by leptin or BMI 55 ated with androgen levels in girls ; however, it was not related to levels. and IL-6. TNF-α alters, and IL-6 inhibits the expression of 56 8 In addition, the adipokine adiponectin was negatively associ- 57 differences of adiponectin seem to develop during the progression of 56 adiponectin (Figure 2). Thereby, a low level of total adiponectin and/or high levels of inflammatory cytokines in individuals with obe- sity can promote the onset of puberty. Many more adipokines are secreted by WAT including omentin, 52,65-67 9,36,62,68 adrenarche in girls with Prader-Willi syndrome. Interestingly, sex puberty. adrenarche; however, both are not required factors. Thus, leptin and adiponectin might be able to influence In gonadarche, leptin can stimulate the secretion of kisspeptin, and subsequently activation of the HPG axis, which eventually increases the expression of estrogen and androstenedione in the ova- 58 2,60 65-67 The expression of these ries (Figure 2). Ob gene in WAT, resulting in the synthesis and secretion of leptin. Thus, high levels of leptin promote onset of puberty in girls via secre- tion of kisspeptin, and estrogen stimulates leptin secretion addition- ally. Moreover, adiponectin can affect the HPG axis due to the expression of adiponectin receptors in the hypothalamus, pituitary In return, estrogen stimulates the expression of the 59 gland, and gonads. onset as it inhibits the secretion of kisspeptin and GnRH in the hypo- thalamus and the release of GH and LH in the pituitary gland, and 2,60-62 52,60 63 girls with central precocious puberty (CPP). Moreover, total adiponectin had negative correlations with progression of puberty in girls (defined by Tanner stages), whereas HMW adiponectin had FIGURE 2 Adipokinesaffectingthe initiation of puberty in girls. Leptin stimulates the release of kisspeptin in KNDy neurons, which activates the hypothalamus to produce gonadotropin releasing hormone (GnRH). In response to the release of GnRH, the pituitary gland secretes follicle stimulating hormone (FSH) and luteinising hormone (LH), which stimulates the ovaries to release estrogen resulting in the formation of secondary sex characteristics in girls. Estrogen stimulates the production of leptin. Adiponectin inhibits GnRH release resulting in reduced levels of GnRH and thereby a delayed onset of puberty. TNF- α and IL-6 inhibit the production of adiponectin and therefore stimulate the onset of puberty In detail, adiponectin is a regulator of puberty thereby inhibiting the onset of puberty (Figure 2). with obesity often have low levels of adiponectin. et al. showed that total adiponectin was significantly lower, whereas high molecular weight (HMW) adiponectin was significantly higher in ment. 55 63 develop a chronic low-grade inflammatory state, which can be indi- cated by a high level of circulating inflammatory cytokines like TNF-α 64 Individuals Sitticharoon positive associations with LH levels and the progression of puberty in 63 visfatin, resistin, and chemerin. and visfatin are expressed in the ovaries. adipokines in the ovaries suggests a role within the reproductive sys- tem; however, the exact biological processes have to be examined. Thus, specifically leptin, adiponectin, and inflammatory cytokines pro- duced by WAT could be permissive key players during an early onset of puberty in girls with obesity. As an exception, HMW adiponectin seems to have a stimulatory effect on peripheral repro- ductive function as HMW is not able to cross the blood brain 63 barrier. 4 | Markers that are used to assess puberty onset in boys are THE ONSET OF PUBERTY IN BOYS spermarche, voice break, testicular volume, and pubic hair develop- 35 spermarche develop in the early stages of puberty onset, voice In women, omentin, chemerin, While pubic hair development, larger testicular volume, and 69 testicular volume increases, which occurs at an average age of break usually appears in later stages of puberty. Generally, first 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 6 of 10 NIEUWENHUIS ET AL. 11.9 years, followed by the development of pubic hair at 12.2 years of average, and lastly, boys experience spermarche around an aver- 55 related with leptin levels. Thereby, leptin plausibly has a minor impact in adrenarche in boys. Since leptin receptors are found in the hypothalamus, pituitary gland, and testes, they might be involved in the onset of puberty by affecting the HPG axis during gonadarche. Leptin stimulates the release of kisspeptin and GnRH, and as a consequence, it accelerates the onset of puberty (Table 1, Figure 3). In contrast, adiponectin inhibits the secretion of GnRH, GH, LH, and FSH therewith delaying the onset of puberty. However, adiponectin levels are generally lower in men compared with women and even lower in men with obe- age age of 13.4 years. 70 4.1 | Fat storage Many aspects of the reproductive physiology are energetically demanding,71 and therefore, an adequate energy level is necessary. In boys, a dynamic change in body composition occurs around the age of 10 to 13 years, in which they gain approximately 40% of sity. culating inflammatory cytokines. levels can stimulate the HPG axis and therewith an early onset of puberty in boys. Nevertheless, leptin can inhibit the production of tes- 72 mostly consisting of lean mass, which causes exhaustion of most of fat. Subsequently, a growth spurt follows in which they gain tissue 72 in boys, an adequate amount of body fat is important in the onset of their body fat. These alterations in amount of body fat indicate that 4.2 | Puberty in boys is initiated by the release of kisspeptin. As mentioned before, this activates the HPG axis, resulting in the release of GnRH from the hypothalamus, and consequently the release of LH and FSH 9,74 puberty. tosterone from the testes, to estrogen (Figure 3). of the development of secondary sex characteristics in boys. Additionally, leptin can affect fertility in men as it can modulate the nutritional support of spermatogenesis, and moreover, dysfunction of spermatogenesis is associated with an increased leptin level and 73 58 2,60-62 HPG axis from the pituitary gland (Figure 1). and LH stimulates the secretion of testosterone from the testes, which inhibits the release of kisspeptin from the KNDy neurons and 9,48 in men, the release of kisspeptin is more consistent, causing a con- 29,48 subsequently GnRH from the hypothalamus. receptors expressed on KNDy neurons. In humans, KNDy neurons Contrarily to women, LH-induced testosterone levels lead to the stant release of LH. development of secondary sex characteristics in boys. differences between sexes in kisspeptin release are related to a sex- specific and sex steroid-dependent kisspeptin system as estrogen and progesterone modulate kisspeptin activity through the sex-steroid 48 in the infundibular nucleus are involved in negative and positive sex- 48 tal exposure to sex steroids and result in sex-specific differences in steroid feedbacks. kisspeptin release. These sexual dimorphisms are induced by perina- 75,76 4.3 | Adipokines The association between obesity and puberty onset in boys is rather controversial compared with findings in girls. Most studies reported an early onset of puberty in boys associated with increased ate adipose tissue from actual breast tissue. stages are more difficult to assess than female stages as boys lack a more determined marker such as menarche. Thirdly, puberty onset can be indicated by the activation of the HPG axis, and the presence of these secondary sex characteristics is the result of hormonal 2 14,17,22,23,50,51,77,78 BMI, 20,49 all while others reported no associations at Current markers used 79 16,80 or a delayed onset of puberty (Table 1). The presence of excessive adipose tissue can be involved in puberty onset in boys as the secretion of adipokines can modulate both adrenarche and gonadarche. Leptin can affect adrenarche by modulating both the HPG and HPA axes,33 and moreover, androgen levels were positively 55 nal androgen secretion in boys with premature adrenarche was not associated with plasma leptin levels. Nevertheless, enhanced adre- 9 In more detail, 61,62 adiponectin, and individuals with obesity often have high levels of cir- Moreover, inflammatory cytokines, TNF-α, and IL-6, inhibit expression of the leptin receptor in the testis. FSH induces spermatogenesis, too. function and role still have to be examined. 64 High leptin and low adiponectin and fat tissue can convert testosterone Both processes might result in the delay 29,61,79 81,82 In men, other adipokines like chemerin are found in the gonads 65 Thus, particularly high leptin and low adiponectin levels stimulate the HPG axis and thereby accelerate the onset of puberty in boys. Additionally, leptin can dysregulate the development of secondary sex characteristics and spermatogenesis by affecting testosterone levels and nutritional sup- port of spermatogenesis. 5 | LIMITATIONS AND FUTURE RESEARCH DIRECTIONS Even though multiple epidemiological studies have shown the link between puberty onset and obesity, there are some important limita- tions. Firstly, determining both the onset and stage of puberty is rather difficult. For instance, assessing the stage of breast develop- ment in girls with obesity is complicated as clinicians should differenti- 2 changes in response to the activated HPG axis. to determine the onset of puberty refer to secondary sex characteris- tics, such as testicular volume in boys and breast development in girls. A more accurate measurement of puberty onset would be to combine secondary sex characteristics with plasma or serum hormone level measurements such as LH, FSH, adipokines, e.g. leptin. Thereby, differences in puberty measurements could explain variations in the age of puberty onset between boys and girls within different Thereby, resistin is expressed in the testes of rats, but its exact 83 Secondly, male pubertal 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License NIEUWENHUIS ET AL. 7 of 10 FIGURE 3 Adipokines affecting the initiation of puberty in boys. Leptin activates kisspeptin secretion in KNDy neurons, this activates the production of gonadotropin releasing hormone (GnRH) from the hypothalamus. GnRH stimulates the pituitary gland to secrete follicle stimulating hormone (FSH) and luteinising hormone (LH), activating the production of testosterone from the testes allowing the development of secondary sex characteristics. Leptin also inhibits the production of testosterone, which may cause a delayed onset of puberty. Adiponectin inhibits GnRH release. Low levels of adiponectin, as a result of TNF-α and IL-6 expression, lead to a reduced inhibition of GnRH. In response to GnRH release, the pituitary gland will secrete FSH and LH, and the testes will produce testosterone resulting in the development of secondary sex characteristics in boys countries, and In addition, the inclusion of a of puberty. ferent time points is complicated, as subjects examined several decades ago presented pronounced differences concerning lifestyle patterns such as nutrition and exercise habits. Lastly, obesity or over- weight is often determined by BMI, a classification based on weight and height measurements. Additionally, it is important that all studies studies or across continents, ethnicities proper age range (8-16 years) is important when assessing the onset (Figure 4). 12-15,17,20-23,49,77-79,84,85 30,47 Furthermore, comparison between studies from dif- 86 Specifically in children, BMI is often dependent on age and growth use the same anthropometric standards and sex-specific cut-offs. 13,14,16-23,49-51,77-80 fat and would represent a more accurate measurement in its regard. Based on this review, several suggestions can be made for further research. Firstly, the roles of adipokines like resistin, chemerin, visfatin, and omentin in puberty onset, fertility, and sexual maturation should be examined in detail. Secondly, future research examining the onset of puberty should combine indicators of puberty onset (e.g. breast development or testicular volume) with plasma or serum hor- mone measurements such as LH, FSH, sex-steroids, adipokines (e.g. spurts. ment in case of growth spurts. distribution of body fat should be taken into account in determining puberty and obesity in children. For instance, the body adiposity index (BAI), which was introduced in 2011 by Bergman et al.,87 uses hip cir- cumference and height in order to estimate the percentage of body 87 Thereby, BMI is a less accurate measure- F I G U R E 4 87,88 Therefore, both percentage and Average age of puberty onset in Europe, China, and the United States according to several studies from Table 1. Age of puberty onset ranges from 8.47 to 13.33 years in girls and from 8.63 leptin), and body fat distribution (e.g. BAI,87 waist-hip ratio's and/or dual-energy X-ray absorptiometry (DXA)2). Additionally, defining con- sistent and general measurements of puberty in both boys and girls, combined with a proper age range (8-16 years), would facilitate the comparisons between different studies and their results. 12-15, 17, 20-23, 25-29, 31 to 13.7 years in boys. included if average age of markers used to assess puberty was not reported. Pink: girls. Blue: boys Studies (Table 1) were not 39, 56 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 8 of 10 NIEUWENHUIS ET AL. 6 | CONCLUSION In conclusion, epidemiological data regarding obesity and puberty onset in girls show similar outcomes as adiposity results in the early onset of puberty in girls. The majority of the studies examining boys with obesity indicate an early onset of puberty, while not all reported an earlier onset of puberty. In detail, high leptin, TNF-α, and IL-6 levels combined with low adiponectin levels stimulate the activation of the HPG axis in girls and boys with obesity, and 5, 45, 50, 51 REFERENCES 1. Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology, and comorbidities to clinical assessment and treatment. May- o Clin Proc. 2017;92(2):251-265. 2. Reinehr T, Roth CL. Is there a causal relationship between obesity and puberty? The Lancet Child & adolescent health. 2019;3(1):44-54. 3. WorldHealthOrganization. Facts and figures on childhood obesity. 2017. 4. Guglielmi V, Sbraccia P. Obesity phenotypes: depot-differences in adipose tissue and their clinical implications. Eat Weight Disord. 2018; 23(1):3-14. 5. Gomez-Hernandez A, Beneit N, Diaz-Castroverde S. Escribano O. Dif- ferential role of adipose tissues in obesity and related metabolic and vas- cular complications. 2016;2016:1-15, 1216783. 6. Zwick RK, Guerrero-Juarez CF, Horsley V, Plikus MV. Anatomical, physiological, and functional diversity of adipose tissue. Cell Metab. 2018;27(1):68-83. 7. Gulyaeva O, Dempersmier J, Sul HS. Genetic and epigenetic control of adipose development. Biochimica et Biophysica Acta (BBA)â Molecular and Cell Biology of Lipids. 2019;1864:3-12. 8. Khan M, Joseph F. Adipose tissue and adipokines: the association with and application of adipokines in obesity. Forensic Sci. 2014;2014: 711-724, 328592. 9. Alotaibi MF. Physiology of puberty in boys and girls and pathological disorders affecting its onset. J Adolesc. 2019;71:63-71. 10. Cousminer DL, Stergiakouli E, Berry DJ, et al. Genome-wide associa- tion study of sexual maturation in males and females highlights a role for body mass and menarche loci in male puberty. Hum Mol Genet. 2014;23(16):4452-4464. 11. Ahmed ML, Ong KK, Dunger DB. Childhood obesity and the timing of puberty. Trends in endocrinology and metabolism: TEM. 2009;20(5): 237-242. 12. Biro FM, Pajak A, Wolff MS, et al. Age of menarche in a longitudinal US cohort. J Pediatr Adolesc Gynecol. 2018;31(4):339-345. 13. Currie C, Ahluwalia N, Godeau E, Nic Gabhainn S, Due P, Currie DB. Is obesity at individual and national level associated with lower age at menarche? Evidence from 34 countries in the Health Behaviour in School-aged Children Study. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2012;50(6): 621-626. 14. De Leonibus C, Marcovecchio ML, Chiavaroli V, de Giorgis T, Chiarelli F, Mohn A. Timing of puberty and physical growth in obese children: a longitudinal study in boys and girls. Pediatr Obes. 2014; 9(4):292-299. 15. Flom JD, Cohn BA, Tehranifar P, et al. Earlier age at menarche in girls with rapid early life growth: cohort and within sibling analyses. Ann Epidemiol. 2017;27(3):187-93.e2. 16. Glass NA, Torner JC, Letuchy EM, et al. The relationship between greater prepubertal adiposity, subsequent age of maturation, and bone strength during adolescence. Journal of bone and mineral research: the official journal of the American Society for Bone and Min- eral Research. 2016;31(7):1455-1465. 17. Holmgren A, Niklasson A, Nierop AF, et al. Pubertal height gain is inversely related to peak BMI in childhood. Pediatr Res. 2017;81(3): 448-454. 18. Kaplowitz PB, Slora EJ, Wasserman RC, Pedlow SE, Herman- Giddens ME. Earlier onset of puberty in girls: relation to increased body mass index and race. Pediatrics. 2001;108(2):347-353. 19. Kelly Y, Zilanawala A, Sacker A, Hiatt R, Viner R. Early puberty in 11-year-old girls: Millennium Cohort Study findings. Arch Dis Child. 2017;102(3):232-237. 20. Lazzeri G, Tosti C, Pammolli A, et al. Overweight and lower age at menarche: evidence from the Italian HBSC cross-sectional survey. BMC Womens Health. 2018;18(1):168-174. thereby an early onset of obesity. leptin can inhibit the production of testosterone in boys and subse- quently inhibit the development of secondary sex characteristics affecting spermatogenesis. for other adipokines, like resistin and omentin, are present in the testes and ovaries suggesting a role in puberty or reproduction; 58, 71 however, their plausible function is still unknown. that adipokines may be key regulators in an early onset of puberty in both girls and boys with obesity, specifically by affecting the HPG axis during gonadarche. Future research should focus on assessing puberty onset by measuring consistent puberty markers and determine the percentage of body fat and its distribution and adipokines and hormone serum levels particularly involved in the HPG axis. CONFLICTS OF INTEREST The authors declare no conflict of interest. FUNDING INFORMATION This research was funded by Europees Fonds voor Regionale Ontwikkeling (EFRO), project BriteN 2016. ORCID Ilse A.C. Arnoldussen Amanda J. Kiliaan https://orcid.org/0000-0002-7395-5284 https://orcid.org/0000-0002-2158-6210 13, 14, 16-26, 29-32 Furthermore, several receptors Nevertheless, We conclude Search strategy We searched PubMed for articles published before Novem- ber 15th, 2019 using relevant keywords, including âonset of puberty and adiposity/obesityâ, âonset of pubertyâ, âchildren with obesityâ, âadipose tissueâ, âchildhood obesityâ, âadiposityâ, âobesityâ, âadipokine(s)â, âHPG axisâ, âadipokines ovary/ova- riesâ, or âadipokines testesâ, either alone or in combination. Selection criteria used were English language, longitudinal or cross-sectional studies assessing the onset of puberty, including menarche, thelarche, spermarche, or voice break, combined with high BMI or obesity/adiposity, and articles assessing or reviewing adipokines and its effects on the reproductive system. 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License NIEUWENHUIS ET AL. 9 of 10 21. Lian Q, Mao Y, Luo S, et al. Puberty timing associated with obesity and central obesity in Chinese Han girls. BMC Pediatr. 2019; 19(1):1-7. 22. Deng Y, Liang J, Zong Y, et al. Timing of spermarche and menarche among urban students in Guangzhou, China: trends from 2005 to 2012 and association with Obesity. Sci Rep. 2018;8(1):263-270. 23. Li W, Liu Q. Association of prepubertal obesity with pubertal devel- opment in Chinese girls and boys: a longitudinal study. 2018;30: e23195. 24. Mendle J, Beltz AM, Carter R, Dorn LD. Understanding puberty and its measurement: ideas for research in a new generation. Journal of research on adolescence: the official journal of the Society for Research on Adolescence. 2019;29(1):82-95. 25. Pagani S, Meazza C, Gertosio C, Bozzola E, Bozzola M. Growth hor- mone receptor gene expression in puberty. Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme. 2015;47:581-584. 26. Abreu AP, Kaiser UB. Pubertal development and regulation. Lancet Diabetes Endocrinol. 2016;4(3):254-264. 27. Aguirre RS, Eugster EA. Central precocious puberty: from genetics to treatment. Best Pract Res Clin Endocrinol Metab. 2018;32(4): 343-354. 28. Sultan C, Gaspari L, Maimoun L, Kalfa N, Paris F. Disorders of puberty. Best Pract Res Clin Obstet Gynaecol. 2018;48:62-89. 29. Skorupskaite K, George JT, Anderson RA. The kisspeptin-GnRH path- way in human reproductive health and disease. Hum Reprod Update. 2014;20(4):485-500. 30. Dahl SK, Amstalden M, Coolen L, Fitzgerald M, Lehman M. Dynorphin immunoreactive fibers contact GnRH neurons in the human hypothal- amus. Reprod Sci. 2009;16(8):781-787. 31. Navarro VM, Gottsch ML, Chavkin C, Okamura H, Clifton DK, Steiner RA. Regulation of gonadotropin-releasing hormone secretion by kisspeptin/dynorphin/neurokinin B neurons in the arcuate nucleus of the mouse. J Neurosci. 2009;29(38):11859-11866. 32. Zhai L, Liu J, Zhao J, et al. Association of obesity with onset of puberty and sex hormones in chinese girls: a 4-year longitudinal study. PLoS ONE. 2015;10(8):1-12, e0134656. 33. Cizza G, Dorn LD, Lotsikas A, Sereika S, Rotenstein D, Chrousos GP. Circulating plasma leptin and IGF-1 levels in girls with premature adrenarche: potential implications of a preliminary study. Horm Metab Res. 2001;33(3):138-143. 34. Cousminer DL, WidĂ©n E, Palmert MR. The genetics of pubertal timing in the general population: recent advances and evidence for sex-spec- ificity. Curr Opin Endocrinol Diabetes Obes. 2016;23(1):57-65. 35. Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969;44(235):291-303. 36. Lacroix AE, Whitten R. Physiology. Treasure Island (FL): Menarche. StatPearls. StatPearls Publishing; 2018. 37. McDowell MA, Brody DJ, Hughes JP. Has Age at Menarche Chan- ged? Results from the National Health and Nutrition Examination Sur- vey (NHANES) 1999â2004. J Adolesc Health. 2007;40(3):227-231. 38. de Muinich Keizer SM, Mul D. Trends in pubertal development in Europe. Hum Reprod Update. 2001;7(3):287-291. 39. Talma H, Schönbeck Y, van Dommelen P, Bakker B, van Buuren S, Hirasing RA. Trends in menarcheal age between 1955 and 2009 in the Netherlands. PLoS ONE. 2013;8:e60056-e60056. 40. Kaplan HS, Lancaster JB. An evolutionary and ecological analysis of human fertility, mating patterns, and parental investment. Off- spring: Human fertility behavior in biodemographic perspective. 2003;1: 170-223. 41. Mitan LA. Menstrual dysfunction in anorexia nervosa. J Pediatr Adolesc Gynecol. 2004;17(2):81-85. 42. Xu H, Li P-H, Barrow TM, et al. Obesity as an effect modifier of the association between menstrual abnormalities and hypertension in young adult women: Results from Project ELEFANT. PLoS ONE. 2018; 13(11):e0207929-e0207929. 43. Tauqeer Z, Gomez G, Stanford FC. Obesity in women: insights for the clinician. J Womens Health (Larchmt). 2018;27(4):444-457. 44. de Ridder CM, Thijssen JH, Bruning PF, Van den Brande JL, Zonderland ML, Erich WB. Body fat mass, body fat distribution, and pubertal development: a longitudinal study of physical and hormonal sexual maturation of girls. J Clin Endocrinol Metab. 1992;75(2): 442-446. 45. Lassek W, Gaulin S. Brief communication: menarche is related to fat distribution. Am J Phys Anthropol. 2007;133(4):1147-1151. 46. Loomba-Albrecht LA, Styne DM. Effect of puberty on body composi- tion. Curr Opin Endocrinol Diabetes Obes. 2009;16:10-15. 47. Simonneaux V, Bahougne T. A multi-oscillatory circadian system times female reproduction. Front Endocrinol. 2015;6:1-15. 48. Marques P, Skorupskaite K, George JT, Anderson RA. Physiology of GNRH and gonadotropin secretion. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. Endotext.org: South Dartmouth (MA); 2000. 49. Barcellos Gemelli IF, Farias EDS, Souza OF. Age at menarche and its association with excess weight and body fat percentage in girls in the Southwestern Region of the Brazilian Amazon. J Pediatr Adolesc Gynecol. 2016;29(5):482-488. 50. Aksglaede L, Juul A, Olsen LW, Sorensen TI. Age at puberty and the emerging obesity epidemic. PLoS ONE. 2009;4:1-6, e8450. 51. Ribeiro J, Santos P, Duarte J, Mota J. Association between over- weight and early sexual maturation in Portuguese boys and girls. Ann Hum Biol. 2006;33(1):55-63. 52. Budak E, Fernandez Sanchez M, Bellver J, Cervero A, Simon C, Pellicer A. Interactions of the hormones leptin, ghrelin, adiponectin, resistin, and PYY3-36 with the reproductive system. Fertil Steril. 2006;85(6):1563-1581. 53. Castellano JM, Tena-Sempere M. Metabolic control of female puberty: potential therapeutic targets. Expert Opin Ther Targets. 2016; 20(10):1181-1193. 54. Venancio JC, Margatho LO, Rorato R, et al. Short-term high-fat diet increases leptin activation of CART neurons and advances puberty in female mice. Endocrinology. 2017;158(11):3929-3942. 55. l'Allemand D, Schmidt S, Rousson V, Brabant G, Gasser T, Gruters A. Associations between body mass, leptin, IGF-I and circulating adrenal androgens in children with obesity and premature adrenarche. Eur J Endocrinol. 2002;146(4):537-543. 56. Böttner A, Jr K, MĂŒller G, et al. Gender Differences of adiponectin levels develop during the progression of puberty and are related to serum androgen levels. J Clin Endocrinol Metabol. 2004;89(8):4053- 4061. 57. Unanue N, Bazaes R, Iñiguez G, Cortes F, Avila A, Mericq V. Adre- narche in Prader-Willi syndrome appears not related to insulin sensi- tivity and serum adiponectin. Horm Res. 2007;67(3):152-158. 58. Michalakis K, Mintziori G, Kaprara A, Tarlatzis BC, Goulis DG. The complex interaction between obesity, metabolic syndrome and repro- ductive axis: a narrative review. Metabolism: clinical and experimental. 2013;62(4):457-478. 59. Machinal-Quelin F, Dieudonne MN, Pecquery R, Leneveu MC, Giudicelli Y. Direct in vitro effects of androgens and estrogens on ob gene expression and leptin secretion in human adipose tissue. Endo- crine. 2002;18(2):179-184. 60. Dobrzyn K, Smolinska N, Kiezun M. Adiponectin: A new regulator of female reproductive system. Int J Endocrinol. 2018;2018:1-12, 7965071. 61. Martin LJ. Implications of adiponectin in linking metabolism to testic- ular function. Endocrine. 2014;46(1):16-28. 62. Mathew H, Castracane VD, Mantzoros C. Adipose tissue and repro- ductive health. Metabolism: clinical and experimental. 2018;86:18-32. 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 10 of 10 NIEUWENHUIS ET AL. 63. Sitticharoon C, Sukharomana M, Likitmaskul S, Churintaraphan M, Maikaew P. Corrigendum to: Increased high molecular weight adiponectin, but decreased total adiponectin and kisspeptin, in central precocious puberty compared with aged-matched prepubertal girls. Reprod Fertil Dev. 2017;29:2506-2517. 64. Das UN. Is obesity an inflammatory condition? Nutrition. 2001; 17(11-12):953-966. 65. Comninos AN, Jayasena CN, Dhillo WS. The relationship between gut and adipose hormones, and reproduction. Hum Reprod Update. 2014; 20(2):153-174. 66. Singh A, Choubey M, Bora P, Krishna A. Adiponectin and chemerin: contrary adipokines in regulating reproduction and metabolic disor- ders. Reproductive sciences (Thousand Oaks, Calif). 2018;25:1462- 1473. 67. Tsatsanis C, Dermitzaki E, Avgoustinaki P, Malliaraki N, Mytaras V, Margioris AN. The impact of adipose tissue-derived factors on the hypothalamic-pituitary-gonadal (HPG) axis. Hormones (Athens). 2015; 14:549-562. 68. Kang MJ, Oh YJ, Shim YS, Baek JW, Yang S. Hwang IT. The usefulness of circulating levels of leptin, kisspeptin, and neurokinin B in obese girls with precocious puberty. 2018;34:627-630. 69. Lee J, Song J, Hootman JM, et al. Obesity and other modifiable fac- tors for physical inactivity measured by accelerometer in adults with knee osteoarthritis: data from the osteoarthritis initiative (OAI). Arthritis Care Res (Hoboken). 2012;53-61. 70. Bramswig J, Dubbers A. Disorders of pubertal development. Deutsches Arzteblatt international. 2009;106:295-303. quiz 04 71. Elias CF, Purohit D. Leptin signaling and circuits in puberty and fertil- ity. Cell Mol Life Sci. 2013;70(5):841-862. 72. Riumallo J, Durnin JV. Changes in body composition in adolescent boys. Eur J Clin Nutr. 1988;42(2):107-112. 73. Siervogel RM, Demerath EW, Schubert C, et al. Puberty and body composition. Horm Res. 2003;60(Suppl 1):36-45. 74. Zhang J. Gong M. Andrologia: Review of the role of leptin in the regu- lation of male reproductive function; 2018. 75. Kauffman AS, Gottsch ML, Roa J, et al. Sexual differentiation of Kiss1 gene expression in the brain of the rat. Endocrinology. 2007;148(4): 1774-1783. 76. Zeydabadi Nejad S, Ramezani Tehrani F, Zadeh-Vakili A. The role of kisspeptin in female reproduction. Int J Endocrinol Metab. 2017;15:1- 11, e44337. 77. Sorensen K, Aksglaede L, Petersen JH, Juul A. Recent changes in pubertal timing in healthy Danish boys: associations with body mass index. J Clin Endocrinol Metab. 2010;95(1):263-270. 78. Juul A, Magnusdottir S, Scheike T, Prytz S, Skakkebaek NE. Age at voice break in Danish boys: effects of pre-pubertal body mass index and secular trend. Int J Androl. 2007;30(6):537-542. 79. Lee JM, Wasserman R, Kaciroti N, et al. Timing of puberty in overweight versus obese boys. Pediatrics. 2016;137(2):137-146, e20150164. 80. He F, Guan P, Liu Q, Crabtree D, Peng L, Wang H. The relationship between obesity and body compositions with respect to the timing of puberty in Chongqing adolescents: a cross-sectional study. BMC Pub- lic Health. 2017;17:664-673. 81. Ishikawa T, Fujioka H, Ishimura T, Takenaka A, Fujisawa M. Expres- sion of leptin and leptin receptor in the testis of fertile and infertile patients. Andrologia. 2007;39(1):22-27. 82. Martins AD, Moreira AC, Sa R, et al. Leptin modulates human Sertoli cells acetate production and glycolytic profile: a novel mechanism of obesity-induced male infertility? Biochim Biophys Acta. 1852;2015: 1824-1832. 83. Morash BA, Willkinson D, Ur E, Wilkinson M. Resistin expression and regulation in mouse pituitary. FEBS Lett. 2002;526(1-3):26-30. 84. Cabrera SM, Bright GM, Frane JW, Blethen SL, Lee PA. Age of thelarche and menarche in contemporary US females: a cross- sectional analysis. Journal of pediatric endocrinology & metabolism: JPEM. 2014;27(1-2):47-51. 85. Herman-Giddens ME, Steffes J, Harris D, et al. Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network. Pediatrics. 2012;130(5):e1058-e1068. 86. WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995;854:1-452. 87. Akin I, Tolg R, Hochadel M, et al. No evidence of âobesity paradoxâ after treatment with drug-eluting stents in a routine clinical practice: results from the prospective multicenter German DES.DE (German Drug-Eluting Stent) Registry. JACC Cardiovasc Interv. 2012;5(2): 162-169. 88. Marcovecchio ML, Chiarelli F. Obesity and growth during childhood and puberty. World Rev Nutr Diet. 2013;106:135-141. How to cite this article: Nieuwenhuis D, Pujol-Gualdo N, Arnoldussen IAC, Kiliaan AJ. Adipokines: A gear shift in puberty. Obesity Reviews. 2020;21:e13005. https://doi.org/ 10.1111/obr.13005 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are gover
7.015 Hand Hygiene: Practice observation of hand hygiene compliance via the use of a hand hygiene survey tool to be reviewed quarterly at the QAPI committee. (Chapter 10.14 Handwashing & Surgical Antisepsis) Continue infection control education through ongoing orientation to center staff routinely and annual mandatory in-service. Continue to promote hand hygiene awareness for patients and staff by means of educational materials placed throughout the center which references the CDC/WHO guidelines. Needle-stick Injuries: (Refer to Exposure Control Plan) Use of designated safety engineered needles for injections (safety glide needles for injection and autoguard IV catheters) and blood draw. New employee and annual clinical competency for injections will be provided to all staff. The staff will be trained yearly on OSHA, blood borne pathogens and PPE. 7.016 Hand Hygiene Quality in the ASCs: based on AORN (Association of periOperative Registered Nurses) Standards and guidelines Policy: All ASC staff, including physicians, nurses, and other healthcare workers, are required to perform hand hygiene before and after any direct contact with patients, before and after any procedure, and after any contact with potentially contaminated items or surfaces. Hand hygiene must be performed using either an alcohol-based hand rub or soap and water. The alcohol-based hand rub must contain at least 60% alcohol. Staff members must ensure that their hands are free of debris and visible dirt before performing hand hygiene. Hand hygiene must be performed for a minimum of 20 seconds, and hands must be dried thoroughly after washing. Staff members must be trained on proper hand hygiene techniques and will be educated on a regular basis to ensure compliance with this policy. All staff members must comply with this policy and demonstrate compliance during inspections by ASC management and regulatory agencies. Any staff member who fails to comply with this policy will be subject to disciplinary action. ASC management will monitor compliance with this policy through regular inspections and audits and will take appropriate action to address any noncompliance issues. The ASC will maintain records of staff compliance with this policy as part of its infection control program. The ASC will review and update this policy on an annual basis or more frequently as needed to ensure that it remains current with the latest guidelines and standards for hand hygiene quality.
*MCQ Quiz: Understanding Good Practices in Writing AI Prompts** 1. **Q:** What is the first step in crafting an effective AI prompt? - a) Define the objective - b) Select the AI tool - c) Provide examples - d) Choose the target audience 2. **Q:** Why is it important to specify the target audience in a prompt? - a) It helps in choosing the right AI tool. - b) It ensures the output is tailored to the right level. - c) It determines the length of the prompt. - d) It makes the prompt more creative. 3. **Q:** Which of the following is a good practice when writing a prompt? - a) Keep the prompt vague to allow AI flexibility. - b) Include clear and specific instructions. - c) Write a very long and detailed prompt. - d) Start with examples before stating the objective. 4. **Q:** What is the role of examples in a well-structured prompt? - a) To confuse the AI with multiple possibilities. - b) To provide context and clarify expectations. - c) To make the prompt longer. - d) To show off knowledge of the subject. 5. **Q:** When should you select the AI tool in the prompt-writing process? - a) After defining the objective and specifying the audience. - b) Before defining the objective. - c) At the very end. - d) Before writing anything else. 6. **Q:** What is a common mistake to avoid when writing prompts? - a) Being too specific in instructions. - b) Including irrelevant information. - c) Mentioning the target audience. - d) Defining the objective clearly. 7. **Q:** How should the tone of a prompt be set? - a) It should be casual and open-ended. - b) It should be formal and precise. - c) It should change depending on the day. - d) It should be vague to encourage creativity. 8. **Q:** What is the final step in crafting a well-structured prompt? - a) Review and refine the prompt. - b) Select the target audience. - c) Provide examples. - d) Choose the AI tool. https://www.revisely.com/quiz/oEkao
Why and How Managers Plan Importance of planning The planing process Benefits of planning Planning and time management Types of PLans used by managers Long term and short term plans Strageic and tactical plans Operational plans Planning Tools and Techiqunes Forecasting Contrigency planning Scenario planning Benchmaking Use of staff planners Implementing Plans to Achive Results Goal setting Goal management Goal alignment Participation and involvement Planning Def: The process of setting objectives and determining how best to accomplish them Planning at Eaton Corporation âMaking the hard decision before events force them upon you, an anticipating the future needs of the market before the demand asset itself Objectives and goals Identifity the specific results or desired outcomes that one intends to achieve Plan Def: A statement of action steps to be taken in order to accomplish the objectives (goals) Steps in the planning process: Define your objectives Determine where you stand vis-a-vis objectives Develpo premises reagrdsing future conditions Analyze alternatives and make a plan Implement the plan and evaluate results What are the benefits of planning Improves focus and flexibility Imporves action orteitation Imporves coordination and control Imporves time management Time Managment Personal time management tips Do say ânoâ to request that distract you form what you should be doing Dont get bogged down inn details that can be addressed later Do screen telephone calls, emails and meeting request Dont let drop in visitors, text messaging use up your time Do prioritize your important and urgent work Dont become calendar bound by letting other control your schedule Do follow priorities; do most important and urgent work first Some 77% of mangers in one survey said that digital age has increased th number of decisions they have to make 43% said there was less time available to make these decisions Types of plans used by Managers What is teh time horizon Long term vs Short term Long term Look three or more years into teh future Short term plans Typically cover one year or less However: the increasing environmental complexity and dynamism of recent years has severely tested the concept of âlong-termâ planning Plans are subject to frequent revisions Most executives would likely agree that these complexities adn uncertainties challenge how er actually go about planning and how far ahead we can really plan At the very least we can conclude that there is a lot less permanency to long term plans today and that tey are subject to frequent revision Managment reaeracher Eillot Jaques believes tha people vary in their capability to think with different time horizons Types of Plans used by Managers (3 of 5) Strategic plans Set broad, comprehensive and linger term action directions for teh entire organization or major division Vision Clarifies purpose of the organization and what it hopes to be on the future Typical plans Specify how the organizations resources are used to implement strategy Tactical plans in business often take the form of functional plans Functional plans Incidate how different component within the organiztion will help accompnlish the overall strategy Production plans Finacial plans Facilites Plans Logisitc plans Marketing plans Human Resource Plans Operation plans Describe short-term activities to implement strategic plans Policies: Are standing plans that communicate guidelines for decisions Ex: Policies on office romances: The media is quick to report when a top executive or public figures runs into trouble over an office affair. Are there ant policies on office romances? Employer polices on office raltioshiis vary. One survey find teh following: 24% prohibit relationships among employees in the same department 13% prohibit relationships among employees who have the smae supervisor 80% prohibit relationships between supervisors and subordinates 5% have no restrictions on office romances Procedures: Are rules that describe actions to be taken in specific situations Budgets: are single use plans that commit resources to projects or activities Zero based budgets: allocate resources as if each budget were brand new There is no guarantee that any past funding will be renwer. All propsales, old and new, must compete for available funds at teh start of each new budget cycle Forcasting Attempts to predict the future Qualitaive forecasting uses expert opinions Quantitative forecasting uses mathematical models and statiscal aanylsis of historical data dna surveys Contingency planning Identify alternative course of action to take when things go wrong Anticipate changing conditions Contain trigger points to indicate when to activate plan (or a specific course of action) Scenario planning A long term version of contingency planning Identifying alternative future scenarios Plans made for each future scenario Increases organizations flexibility and preparation for future shocks Benchmarking Use of external and internal comparisons to better evaluate current performance Adopting best practices: things people adn organization do that lead to superior performance Staff Planners Experts who assist in all steps of the planning process They help bring focus and expertise to a wide variety of planning tasks Important: Communication between staff planers landline managers is essential for teh success of teh planning process Goal Setting - Always set SMART goal The solution: Goal Aligment Between Team Leader and Team Member Jonintly plan: Set objectives, set standards, choose actions Individually acy: Perform tasks (member), provide support (leader) Jointly control: Review results, discuss implications, renew cycle x4 Collective effort and commitment Participatroy planning Includes in all planning steps that people who will be affected by the plans adn askedd to help implement them Unloacks motivational potential of goal setting Management by objective (MBO) promotes participation Participation increases understanding and acceptance of plan and commitment to success Participatory planning - Number of people involved in teh decision making process Amazon is intensely focused on what it does. It believes in creating tight single-threaded teams, also known as â2 pizza team.â Data and Decision Making What are some of the important competencies managers must have today? Delegate Marketing and technology Manager must have Technological competency Ability to understand new technologies and to use them to their best advantage Information competency Ability to locate, gather, organize and display information for decision-making and problem solving Analytical competency Ability to evaluate and analyze information to make actual decisions and solve real problems What is the difference between Data and Information Data Raw facts and observation Information Data made useful and meaningful for decision-making Important concepts Big data Exists in huge quantities and is difficult to process without sophisticated mathematical and analytical techniques Data production today Bernard Marr is an internationally best-selling author. He helps organizations improve their business performance, use data more intelligently Data mining The process of analyzing data to produce useful information for decision-makers Management Analytics The systematic evaluation and analysis of data to make informed decision Information drives management Bad Data Refers to information that can be erroneous, misleading, and without general formatting The challenge: Can er use the data that is available in the âBig Dataâ Needs to be valid Can not trust everything out there Being ethical Look at the trends Data is structured and unstructured Data BIg Data = Structured + Unstructured Information Drive Management decision making What are the characteristics of useful information Easy to access If its credible Accurate Characteristics of useful information: Timely High quality Complete Relevant Understandable What about bad data It's not credible Miss information If it is not structured/ organized Bias based on opinions Confusing If its updated Bad data Refers to information that can be erroneous miss What are some examples of Management information system Business intelligence -BI Information systems to extract and report data in organized ways that are useful to decision-makers Executive dashboards Visually update and display key performance metrics (or Key Performance Indicators -KPIs) and information on a real-time basis Information needs in organization External Environment Information exchanges with the external environment Gather intelligence information Provide public information Information needs within the organizations (internal Enviroement) Information exchange within the organization Facilitate decision making Facilitate problem-solving Managers as information processors Continually gather, share and receive information Now as much electronic as it is face-to-face Always on, always connected How many people telecommute at least once a week 70% of people globally work remotely at least once a week, Work at home after covid 19 our forecast Our best estimate it that 25-30% of the workforce will be working form home multiple days a week by the end of 2021 As of 2023, 12.7% of full time employees work from home, while 28.2% work a hybrid model Managers as problem solvers Problem-solving The process of identifying a discrepancy between actual and desired performance and taking action to resolve it Ishikawa Fishbone diagram To identify the cause of problems Decision A choice among possible alternative courses of action Performance threat Something is wrong or has the potential to go wrong Performance opportunity The situation offers the chance for a better future if the right steps are taken Problem-solving approaches or style - from textbook Problem avoiders Inactive in information gathering and solving problems Problem seekers Proactive in anticipation of problems and opportunities and taking appropriate action to gain an advantage Problem solvers Reactive in gathering information and solving problem Managers - can approach problems in a systematic or intuitive manner Systematic thinking approaches problem in rational, step-by-step and analytical fashion Intuitive thinking approaches problems in a flexible and spontaneous fashion Multidimensional thinking- applies both intuitive and systematic thinking Managers face structured and unstructured problems Structure problems Are ones that are familiar, straight forward, and clear with respect to information needs Program decisions apply solutions that are readily available from past experiences to solve structured problems Know how to solve them Familiar Know what we are dealing with Unstructured problems Are ones that are full of ambiguities and information deficiencies Nonprogrammed decisions apply a specific solution to meet the demands of a unique problem Commonly faced by higher-level management Crisis decision making A crisis involves an unexpected problem that can lead to disaster if not resolved quickly and appropriately Ruled for crisis management Figure out what is going on Remember that speed matters Remember that slow counts, too Respect the danger of the unfamiliar Value the skeptic Be ready to âfight fire with fireâ Managers make decisions with various amounts of information Certain environment Offers complete information on possible action alternatives and their consequences Risk environment Lacks complete information but offers probabilities of the likely outcomes for possible action alternatives Uncertain environment Lacks so much information that it is difficult to assign probabilities to the likely outcomes of alternative Ex: Certain and uncertain environments: The worldwide Governance Indicators for over 200 countries, comparing distinct environments (Canada-Brazil) Step 1-Identify and define the problem Focuses on information gathering information processing and deliberation Decision objectives should be established What are some common mistakes in definding problems? Common mistakes in defining problems Defining the problem too broadly or too narrowly Focusing on symptoms instead of causes Choosing the wrong problem to deal with Step 2- Generate and Evaluate Alternative Courses of Action Potential solutions are formulated and more information is gathered, data are analyzed, the advantages and disadvantages of alternative solutions are identified Common mistakes: Abandoning the search for alternatives too quickly Step 3- Decide on a preferred course of Action Two different approaches Behavioural model leads to satisficing decisions Classical model les to optimising decisions Behavioural Model Rationality is bounded because: There are limits our thinks capacity Available information (incomplete) Time constraints Step 4-Implement the decision Involves taking action to make sure the solution decided upon becomes a reality Managers need to have the willingness and ability to implement action plans Problems: Lack of participation error should be avoided Step 5 - Evaluate Results Involves comparing actual and desired results The positive and negative consequences of the chosen course of action should be examined If actual results fall short desire results, the manager returns to earlier steps in the decision-making process At all steps, check ethical reasoning Ask these spotlight questions Utility Does teh decision satisfy all constituents or stakeholders Rights Does the description respect the rights and duties of everyone? Justice Is the decision consistent with the canons of justice Caring Is the decision consistent with my responsibilities to care? Issues in decision-making How do errors happen? Heuristics: are strategies for simplifying decision-making Availability Bias: Bases a decision on recent information or events Representativeness bias: Bases a decision on similarity to other situations Anchoring and Adjustment Bias: Bases a decision on incremental adjustment from a prior decision point Framing error: Tring to solve a problem in the context perceived, positive or negative Confirmation Error: Focusing on information that confirms a decision already made Escalating commitment: Continuing a course of action even though it is not working Creative Decision making Creativity is the generation of a novel idea or unique approach that solves a problem or crafts an opportunity Big C: Creativity occurs when extraordinary things are done by exceptional people Little C: Creativity occurs when average people come up with unique ways to deal with daily events and situations The three types of situational creativity drivers Chapter review What are objectives and goals? The specific results or desired outcomes What are the 5 characteristics of great (SMART) goals? Forecasting - Attempts Qualitative forecasting uses options Quantitative forecasting uses mathematical models and statistical analysis of historical data and surveys Scenarios-Oracleâs crystal ball combines qualitative and quantitative methods
âOn this night, we share a roof protecting us from fleets of inequity. Our unification promises a better tomorrow. Those larger than myself, sitting on their marble thrones, sipping blood from cups composed of human skin and singing songs of so-called virtue, grow weaker each moment. Their caravans are revolting. There is hope yet. There is progress! Though tonight may mark a countdown, it is still a celebration. Look at all we have done, not just for Trials but for Palatium Infra as a whole. In four years, when Iâm no longer Sovereignty, the Spoiled Purity and his people will continue to strive. So drink! Smoke! Crush up those exotic plants and snort them! We will not falter, weaken, or wane. Our influence is expanding, and somebody new opens their eyes every day. Even the Silbys of Aculeus have reached alarming potentials despite their embittered minds. So long as you relish in tonight, dance, and pray to your âdeadâ Gods, our revolution shall rise beyond the bounds of class, and when Iâm only a commoner, we shall rise again beyond our brainwashed adversaries! Cheers, my people. Cheers!â Followers raised their cups. Some clinked theirs together. Others stood still and screamed breathlessly in agreement. I smiled with courtesy, then stepped off my platform. My voice still rang across the cellar. Speeches before were grander. Those displays were supposed to be emptying, and yet this one left me bloated, swollen tight. I watched as they popped the corks of their bottles and chanted in the name of Purity. Maybe the quality of my words wasnât what mattered to them anyway, so long as I screamed loud enough. Thereâs no merit in attacking your people, a voice corrected me. âThatâs right,â I said aloud. âKnox, my-my Sovereign!â squealed a nearby devotee, jittering as he stuffed his face with catered pastries. He was one Iâd never seen before or had failed to remember. âLook what Iâve found! Itâs wine, and not the shoddy Infran kind, either. Earth-made with good fruit! I donât know how anyone managed to get their hands on this. Maybe some space travel mischief.â He giggled and held up a small glass bottle. âHow neat.â âI want you to have it, Sir.â I nodded my head. âYes, of course. Thank you.â Backing off into the midst of rowdy disciples, I clutched the bottle. What a waste of grapes. It could have been jam instead. Earthly food had a superior taste, ripe with delicate intricacies and nostalgia, but Palatium Infra had mastered the art of alcohol. Why waste your time with a drunkenness so sad and sickening? The booze of trash. Not many more followers approached me. The barren peroration must have upset them. My hands itched to submerge into my suit pockets, and my legs stood suddenly numb, wobbling. Four more years until Iâm nothing. But tonight, you are nothing. âShut up,â I told myself. Tightly packed together in the corner of the dwelling sat the Sibyls. A mound of writhing fabric and tones of skin made up their unified silhouette. I snapped the strap of the nearest gown, balancing on my hands and knees, waving the bottle before them. In their almost rodent nature, narrow noses prodded my way. Their dresses wrinkled and fell to their ankles. Knees dropped, and eyes widened. Many grumbled at me like hungry she-beasts. Those newer ones with faded curtains for hair, sunken eyes, and dirtied nails looked, hid their face, then sobbed. I imagined them in a pack together, fighting wildly against the Spoiled Purity in their rat decorumâbiting down with square teeth laced with rabies. âIâve got you all something,â I said. âGo back off to your pedestal and yap some more. We donât want it.â A woman rose from the pile and spat. âYou donât even know what it is yet. It's Earth hooch, or more likely a near-flawless replica. I figured you girls would also like a chance to enjoy yourselves tonight.â âYour playmates have been harassing us since the moment you hung the banners and opened the cellar door.â The youngest, with a striking cyan mop upon her head, uncoiled from the mass. What was she now? 20, 21? We celebrated a birthday recently, I thought as she spun around me. âI remember something about a promise. Multiple promises, actually. Are you trying to bribe us into just shutting up and taking it? Because if another sticky, 40-year-old, Earth-born virgin gropes my shoulder, Iâm going to have an aneurysm!â the girl continued. âWhy not an Infran follower? Do you like it when they touch you?â I returned her accusing tone. âIâm sorry, sweet prophets, that you feel Iâve neglected my duties. Iâll keep a better eye out. Remember, you can always just holler if somebody is bothering you. And Anwen, friend, if Iâve ever tried to bribe you with anything, it was certainly the hair dye. I mean, look at you! Such handsomeness!â I exclaimed. The other Siblys began to encircle her, uttering compliments or even announcements of their envy. Anwen disappeared in a wink with flushed cheeks back into the mound. âIâll just leave this here.â Smiling, I set down the bottle. ** â141, 143. . .â I counted each step as I trekked the staircase. There was no doubt I lost track somewhere. The ledges kept spawning under my feet, infinitely multiplying until I wasnât moving at allâswallowing me up in a whirlpool of stone. My tie still hung around my neck, and my blazer remained tied around my hips as a skirt. Streaks of red dribbled off from the cavity in my chest. It was a gorgeous marking, sensual to my fingertips as I traced its edges. Purity, oh, Purity. Purity and his wings of burnt skin. Purity and his many faces. Purity the spoiled. Purity the mutilated. The Silbys did not bother waiting for me. On bare feet, they stormed up the stairs to their room. A trail of red, though in paint unlike mine, streamed after them. None looked remotely near me as they squeaked and gossiped intangibly. I saved them, those Infran broads, enlightened them. As much as they liked to deny it, spit at me, and bask in the thought of their victimhood, in this home, they stood empowered. Youâve done well, my thoughts affirmed, though in the manner of an insincere commentator rather than a hype man. Teeth grace in tile violin goes laundry paper when. It dissolved into an intruding drivel. I rubbed my head and sniveled. âDo you need help, Knox?â called a Silby. Fattened by my coddling, her shadow fell upon me from the doorway steps ahead. I attempted counting again. There mustâve been at least another hundred between me and her. âIâm hallucinating some,â I said, breathing deeply to suppress a burp as I struggled to recall her name. Two syllables. Typically Latin, though sometimes English. Drops of slobber leaked from my mouth. âIâm hallucinating some, Tybal. Do you like your name, Tybal? I would have named you something better. Ty-Tyballinia. No, weâd have to eliminate the âballâ aspect. It sounds too crude.â âOne foot in front of the other,â she said. So I walked. Mess greeted me at the doorway. Dirtied culinary obscured the dark wooden countertops, and the sink lay running. I approached the kitchen table, sat, and set my face down upon its cool wooden surface. Assaulting my nose was the smell of neglected flowers, like soil mixed with the kind of sweet cough medicine that would have left me gagging as a child. Open windows whispered songs of the twilight hour through the vessels of busy trolleys and shooting guns. My mouth strained to vomit, but there was nothing in my stomach to regurgitate except the petals of Stultoâs bloom, which came out effortlessly in little sputters. Teetering, I stood up and brushed disgorged plant parts off the tabletop. âLove,â I said as I slogged up yet another staircase. âAre you awake?â She said sheâd wait. Somebodyâs gotten her. No, she always misses movie night. That sleepyhead, I assured myself. There was a stirring amidst the manorâs cloak of dusk. Portraits of myself, my wife, and my daughter turned to face me as the hallway lights flickered, escaping their quartz frames to penetrate my ears with nonsense. The taxidermied heads of Infran creatures bared their teeth. I stopped to stare at my favorite, an adabactor with daunting spiked tusks poking out from its forehead. Its nose remained black and sharp, and its eyes wide with malice. âWhere is my Spes, Adaba-boy? Is she sleepy?â Thereâs someone in the house. The sounds of the stirring rose along with my blood pressure. Footsteps orbited around me, drawing near and far and then near again, little dancers in the dark. The carpet immersed me in its mass of purples and blues, leaving my skin stained indigo and my vision abstracted. I toiled to reach the master bedroom across the aisle as it stretched out to me with bright lights and celestial howling, like a dove struggling in a pool of oil. Never again with Stultoâs bloom. Never again on what was already a bad night. My hand brushed the doorknob, and the high abruptly faded into only a persistent hum-buzz twirling around my brain. The portraits returned to their typical depressionâSpes posing with her ax, Ariâs school photo, and myself in the cap I wore when addressing the military with the Verbis emblem embroidered in its center. All lifeless shots. Who were they for when they captured not the subjectâs essence but only some fragment of their identity? They used to feel personal, not advertisements of some supposed characters. Servants, babysitters, and likewise civilian guests, I reminded myself, mustnât forget whose home theyâre in. Yet my body moved independently, taking Ariâs from its hook and laying it backward against the wall to hide her distant grin and tamed posture. It was time for new pictures. Sweet ones, real ones; time was ticking. I approached my own when the stirring began again. Groans and squeals erupted from the vents as if someone had set a pen of pigs loose in my crawlspace. No, not the crawlspace, my bedroom door. I turned the ruby knob. Underneath a blanket wrestled my two squealing piglets, their skins melting together beneath the layer of duvet. Fishnet leggings and manicured nails outstretched and scraped at the sheet beneath them. One raised its head, a salmon-colored man with sweat running down his forehead. Through the crack in the door, we met eyes, his Infran Dr. Sesuss nose flaring its narrow nostrils. No mark of the Spoiled Purity existed carved onto his naked body. My chest felt tight. I stepped back. I was suffocating. Spes emerged from the linens, her hair flowing down her back and her dark skin glistening in front of the bedroom window. She giggled and held the man, the blanket falling and revealing inches of her body I had not seen in months. âDarling,â whispered the rosy-faced man, âlook.â He was unfathomably ugly and grotesquely young, with beady, lifeless pupils that dilated when he faced me. The excess flesh on his face sagged while he bit down on his thin lips. My wife faced me, gasped, and strained to cover herself. Suddenly, I was a stranger. A small child who had walked into his parents having sex. I unfurled the door completely. âGet out of my house,â I said. The man stayed in place. âGet out of my house,â I repeated. âKnox,â Spes began. Tears ran down her round cheeks. âShut up!â I turned to the man, picking up a marble trophy from on top of my dresser. âGet out of my house! Iâll kill you!â âKnox!â Spes sobbed. âGod damn it! I hate you! You barely look at me. Every day, thereâs less passion. God, God, God, I donât want to fuck a dead man!â she screamed, âYou get out! Get! Get!â My hands wrapped tighter around the statue. That pig of a man was attached to her at the side, his face equipped with a scowl that challenged mine. He thought I was weak; frail like a decaying dementia-ridden senior. I imagined his skull bashed in, his scowl gone, and the feist and confidence in his face beaten into numbness. A new portrait was in order of such brutality, him as a splintered slab of wood, rashed and beaten, a carcass licking my boot. The churning in my brain had come back. Every wall shook. Clock faces came to life and rang in alarm. Indescribable noises caressed my eardrum before breaking into sorrowful weeps. Was it my own? I stared at Spes in motionless frenzy, clenched my teeth, and screamed like a siren. Passionless. What a lie! An excuse, more like. One that erased all my ventures, reducing me to a nobody. But I was not a nobody. I thought of my sect, my campaigns, my endurance through the political brutality of my empty hive-mind worldâeven my collection of literature, maps, and artifacts. I thought of daring nights alone with Spes when we were young, ravaging each other, two sardonic eggheads suddenly overcome with desire. The veins in my neck throbbed as I gasped for air. It was all I had. I threw the figurine at the manâs head. Eye shut, I heard the thud. A million singing voices of victory flooded out of the cracks in the floorboard. Proving myself a man to the woman I loved in a display of fervent violence was passion. I strained my ears for his cries, though I did not look yet. There had to be a pause, a moment of relief, where I stood tall as a skyscraper and seemingly fought to stay contained in front of my wife and her wounded, quivering paramour. Frantic footsteps rushed off the bed and past my side. I turned and grappled against myself to seize my wifeâs shoulder. âSpes!â My eyelids lifted. Escaping was the man with that same numb expression in which I had imagined him. âYouâre insane,â he said. I swiveled back towards the bed. With her curly locks flowing over her breasts and her limbs bent at her sides, Spes sat limp pressed against the headboard, her forehead bludgeoned and the statue resting on her stomach. Lips pursed and sweet, my Renaissance beauty reclined there in the guise of a squashed bug. But she was not dead. The desk ornament I flung was only the size of my shoe. Spes, that dramatist, may have been slightly hurt but was far from dead. She only wanted me to think she was to observe me at my most distraught, like a leech feeding on misery. âGet up.â Staggering toward the bed, I said. âYou wanted passion? I showed you passion. âShoved it right into your head. Of course, we both know who that gesture was meant for. . .â I fumbled to find my wit. Cold skin met my hands as I stroked her face, unable to resist checking her pulse, even though she was not dead. âI love you, Spes,â I said. Rain pelted against a nearby window. âSpes, please. Please.â No vibration answered my plea. I lifted my hand, sitting next to her now. Tears did not come. There was not any blood on the trophy, but when I picked it up, it felt to be now only a cruel instrument. It depicted a younger me in white marble, with my glasses and collared shirt being the only things painted. Both were in pink. It was a favorable color. I scrambled from the bed to vomit pure digestive bile on the rug. My stomach heaved. I ran my nails along every piece of myself I saw, a dog chasing my tail. As I slammed myself against walls and convulsed, my own heart grew ever louder in my chest. âDad? I heardââ Ariâs slippered feet hammered across the floor. âMom? Mom?â I kept my eyes on the storm. Silence fell. âShe-She isnâtâyourâ.â Gasps interrupted every syllable she spoke. âYouâre a murderer. Bad. Like they said,â she breathed, â You beat her!â The words became mush, alphabet soup. Ari ran back down the hall. âMy-My mom is dead. . . .Yes. . . Manor of the Trials Sovereignty. . .Ari Sorkin. . . Iâm afraid heâs going to hurt me,â she said, presumably over the phone. It was all too fast. I crawled onto the windowsill, opened the glass, and let myself plummet into the alley below. Gusts of wind howled. The lack of motion or sensation informed me I had passed and again lived. Another Palatium Infra, another strange planet in which the celestial endowed rotting men with the opportunity to inhabit. Was this it? Was it all just an impossible limbo of galactic traveling? My surroundings were overwhelmingly gray, an abyss of clouds. Perhaps I had now met the real coming world, and my family and old friends lived here, ready to rush to my sides, lift me up, and jump for joy. Spes would be there. She would be enraged, but at least sheâd be there. You are a bad man. You are a bad man. My eyelashes fluttered. There was a tugging sensation in my leg. The fog was wavering along with my ascendance. âNo,â I yearned, trying to grip the clouds and stick them in place. âStay with me.â But the peace was fleeting. I felt the cement under me and the moist garments clinging to my figure. My leg burned. Carefully, I craned my neck, only to observe the promenade as my surroundings. The most underwhelming of filth and danger, individually Infran. Forever my coming world. What a fool I was, having forgotten my blessing. Those idiot Gods could not tell the difference between assassination and self-infliction; a faulty insurance plan. The urge to cry at last set over me, and so I sat and wailed hot salvia into my palm, shielding my mouth to muffle the noise. Thunder echoed my hushed howling. Raindrops turned to pebbles. Under the ambiance of the stormy night, I could have sworn I heard troops stomping, guns cocking, and the chanting of my name. They had all been waiting for this. Billboards came to life, and I could only sit and spectate as the scenery flashed red. I inhaled fear and sobriety through runny nostrils. âTrials Sovereign Vsevolod âKnoxâ Sorkin is currently at large for the suspected homicide of Spes Sorkin, breaking the first term of the Sovereignty Charter. We now instruct you to report any sightings of the Earth-born, caucasian, roughly 195 centimeters tall, brown-haired, and brown-eyed man to your local Guard post. One can identify the suspected convict specifically by an occult tattoo of Purityâs Coronet on his lower back. No attempted execution or elongated punishment will take place until our Guards conduct an autopsy proving his guilt, per Lifeâs 1238 commandment. We cannot be sure when or if the Gods will revoke his blessing. Remember, when Gods frown upon strife, opt for a peaceful life. We permit all grieving festivities until Cagidus 4th. Good year!â towering buildings sang out in broadcast, repeating that same convoluted message quicker the instant it ended. Sometimes, the announcer spoke in Latin for the Infran children, other times in Chinese, Hindi, or Spanish to cater to those of irrelevant tongues. You arenât a bad man. You are a stupid boy. Puddles sloshed. Somebody was approaching. I didnât dare waste any remaining energy avoiding the Guards and their prodding blades. How did that phrase go? You dug your grave. Now lie in it. And so I embraced the cement. âKnox?â said the Guard. No, her tone was too sincere, and no authority would proceed in such a manner. There wasnât confirmation on whether or not I was armed, and it wasnât as if she could shoot me first. She was a partygoer, having just left from the cellarâs backdoor. I shooed her away with my hand. She hovered, and I discerned her shadow hesitating over my body. A man could not rot in peace. âCome on, get up! Theyâre after you!â Hands reached around my torso, struggling to handle my weight as they urged me onto my feet. That leg, the burning one, my right, trembled and bent unnaturally upon impact with the ground. The partygoer slung my arm over her shoulder, balancing me. My eyes caught a glimpse of a cyan mop. âAnwen?â I rasped, âhu-who let you out?â Keys jangled in her handsâmy keys. âI escaped,â she said casually, coercing me to walk beside her. âQuicken your pace. I just heard somebody on your front porch. âYou see that compost bin down the alley? Weâre gonna burrow right down into the depth of that. If they open it and uncover us, Iâll be on top, and I can hide you and act like Iâm just a homeless amica trying to take a nap.â With a tightening grip, she led me like livestock to the stinking crate. âI donât understand, Anwen,â I said. âTheyâre going to torture and kill you, stupid. You know theyâve been wanting to, and you just handed the opportunity to them!â âI understand that.â It was becoming increasingly challenging to hide the fragility emerging in my voice. âYou said you were escaping. Why stop and help your captor?â âWhat else could I do? Leave you there?â Attempts to shove my wounded body inside its mass of discarded fruits and vegetables began. She yanked down upon my head and submerged me in the fertilizer sea. The evidence grows indisputable, I thought as I stared at the abruptly humane Infran girl, diving in after me, that I belong here. âDamn me to hell! Iâve killed her! My love is dead!â an uncontrollable cry leaped from my mouth. âShut up! Soon youâll be, too, if you donât quiet down.â The actual noise of the Guards darted past us: disorientated marching, guns clanking against each other, cluttered belts rattling, the Latin squawking. One paused to open the binâs lid, though only rummaged through the surface layer of peat before carrying on. âWhat are they talking about? I struggle with my Latin,â I whispered. âThe search, mainly.â Aggression remained firey in Anwenâs clenched jaw. Though she sat on top of me, there was a monumental distance between our rain-soaked forms. I curled up into a ball, ducked my head between my knees, and dreamt of Spes, ignoring the stench of spoiled food rising from every crevice of my dwelling. The next coming world was due to adopt me again as I forced sleep. I prayed for a canyon of fluffy haze, where I waltzed with pale memories but found nothing but the petrifying stillness of my mind. Killed and ran. Violent as a Guard just to prove a point and watch it backfire. Why would any heaven want to welcome me? I clung to the picture of Spes in my head like it was the last ember of an extinguished flame. âDid you mean to kill her?â Anwen interrogated. âSomeone like you would immutably believe yes.â âAnd who is someone like me? You canât even treat me like a person for a moment, can you?â grating drama decorated her words. âYou know my opinions. I have not seen much of your or your breedâs faces besides that of cruelty and ignorance.â I retorted. âI just saved you! Does that make me cruel and ignorant?â âIt makes you an idiot, which is another word for somebody ignorant.â âAnd why am I an idiot?â She asked. âBecause you helping me does no good. Thank you anyhow. Now, do yourself a favor and scram.â As she bent her leg in anticipation, preparing to strike me on the forehead, I sensed an invisible withdrawal widening the gap between us. âYou never answered my question,â Anwen took me by the end of my tattered tie suddenly and started her game of shepherd and sheep over again, pulling me back up to the crateâs exit. It appeared as a shining light at the end of a maze of rubbish and mold. âNo. Of course not. Spes was my everything,â I sniffled. âI knew it. You couldnât even bring yourself to hit us, let alone murder your wife. The girls and I always figured you were sensitive.â My heart rate quickened. Today was one of humbling and miseryâone to pray a hail spike would fall from the sky as sharp as a needle, pierce into my eyelid, and lobotomize me. I wished I could have merely died or hit my head hard enough not to have to deal with it all. No, I wished I was Anwen with her snarky, careless glow and lack of depth in her eyes. As we emerged from the compost bin together, I fantasized about strangling her until her face turned purple, her weakening spirit no longer categorizing me as âsensitiveâ, but the thought could only remind me of wielding that trophy and the microscopic traces of my wifeâs tender skin tainting it, which turned my guts inside out. âThatâs why I think you could use a little help,â Anwen said, âIt seems like you canât walk, either. Your leg is all twisted up.â She undid one of her trim pigtails and handed me the band. âTake off your tie and put up your hair. âWill make you less recognizable. Then swallow your pride and stick with me.â
SPANISH STUDENTS 10/22/25 In the sentence 'The author chose to juxtapose the wealthy neighborhood with the impoverished area to highlight social inequality,' what does 'juxtapose' most likely mean based on context clues? * 1 point to separate completely to describe in detail to criticize harshly to place side by side for comparison When reading 'This paradox confused everyone: the more he tried to save time, the less time he seemed to have,' what can you infer about a paradox? * 1 point a mathematical equation a simple solution a type of poem a contradictory statement that reveals truth The passage states: 'The author's use of symbolism was evident when the broken mirror represented the character's shattered dreams.' Based on this context, symbolism involves: * 1 point using objects to represent deeper meanings creating rhyming patterns writing in chronological order using literal descriptions only In the text 'Please elaborate on your answer by providing specific examples and detailed explanations,' the word 'elaborate' suggests the need to: * 1 point use simpler words change the topic add more detail make it shorter The critic wrote: 'The actor's performance captured every nuance of emotion, from subtle sadness to barely contained rage.' What does 'nuance' refer to in this context? * 1 point subtle variations in meaning simple emotions loud expressions obvious differences When the text says 'The implication of her silence was clear to everyone in the room, though she never spoke a word,' what does 'implication' mean? * 1 point a command given a direct statement a question asked a conclusion drawn indirectly The scientist stated: 'Based on our limited observations, our hypothesis suggests that plants grow faster with classical music.' What is a hypothesis? * 1 point a type of experiment a proven fact a final conclusion a possible explanation needing more evidence In 'Three witnesses were able to corroborate the defendant's alibi, strengthening his case significantly,' the word 'corroborate' most likely means: * 1 point to question or doubt to confirm or support to change the story to ignore completely The passage reads: 'The student needed to justify her controversial thesis with solid evidence and logical reasoning.' What does 'justify' mean here? * 1 point to make it longer to make excuses for to avoid explaining to prove something is reasonable When the text states 'The researcher was able to synthesize information from five different studies to create a comprehensive theory,' what does 'synthesize' involve? * 1 point copying one source exactly combining multiple sources to create something new rejecting all previous research focusing on only one idea When a reader encounters 'The symbolism in the novel was complex, with the recurring image of doors representing new opportunities throughout the story,' they should: * 1 point memorize all symbols skip symbolic passages look for deeper representational meanings focus only on the literal meaning If a teacher says 'Your essay needs more elaboration - expand on your main points with examples and analysis,' what critical thinking skill is being requested? * 1 point developing ideas with supporting details summarizing briefly using fewer examples changing the topic entirely In the passage 'The dark clouds gathering on the horizon seemed to foreshadow the troubles that would soon befall the village,' what literary technique is being demonstrated? * 1 point The author is using environmental details to hint at future plot developments The author is focusing on realistic weather descriptions The author is using weather to predict actual meteorological events The author is describing a coincidental weather pattern When analyzing 'Sarah knew the antagonist in her favorite novel wasn't just evilâhe represented the fear of change that many people experience,' what deeper understanding about antagonists is revealed? * 1 point Antagonists are always completely evil characters Antagonists can represent abstract concepts or human struggles Antagonists must be human characters Antagonists only exist to create action scenes In the sentence 'The protagonist's journey wasn't just about reaching the destinationâit was about discovering who she truly was,' what does this suggest about effective protagonists? * 1 point Protagonists must always succeed in their missions Protagonists should remain unchanged throughout the story Protagonists undergo both external and internal development Protagonists should focus only on external goals When the text states 'The word 'home' carried different connotations for each characterâwarmth and safety for some, confinement and obligation for others,' what critical reading skill is being highlighted? * 1 point Memorizing dictionary definitions Understanding that words have only one correct meaning Identifying grammatical structures Recognizing that word meanings can vary based on personal experience In 'While the denotation of 'snake' is simply a reptile, the author's use of it to describe the character suggests something far more sinister,' what analytical skill is required? * 1 point Understanding reptile biology Memorizing animal classifications Distinguishing between literal and figurative meanings Identifying sentence structure When examining 'The author's tone shifted from hopeful in the opening chapters to increasingly cynical as the story progressed,' what does this reveal about sophisticated writing? * 1 point Tone is unimportant in storytelling Tone changes reflect the author's developing attitude toward the subject Only the ending tone matters Authors should maintain the same tone throughout In analyzing 'The theme of the novel wasn't stated directly but emerged through the characters' repeated struggles with moral choices,' what does this demonstrate about themes? * 1 point Themes develop through patterns in the narrative Themes are only found in the conclusion Themes should always be explicitly stated Themes must be simple moral lessons When the passage reads 'From the character's nervous glances and hesitant speech, readers can infer that she's hiding something important,' what critical thinking process is being described? * 1 point Following explicit plot statements Memorizing character descriptions Making random guesses about character motivations Using textual evidence to draw logical conclusions In 'The ending was deliberately ambiguous, allowing readers to decide whether the character's actions were heroic or selfish,' what does this suggest about sophisticated literature? * 1 point Good stories always have clear, definitive endings Unclear endings indicate poor writing Ambiguity can enhance reader engagement and interpretation Authors should avoid confusing readers When analyzing 'The controversial decision to ban the book sparked debates about censorship versus protecting young readers,' what critical thinking skill is most important? * 1 point Choosing one side immediately Examining multiple perspectives before forming an opinion Avoiding difficult topics entirely Following popular opinion In 'Each character's perspective on the same event revealed how personal experiences shape our understanding of truth,' what deeper concept is being explored? * 1 point All perspectives are equally valid Perspective is unimportant in understanding events There is only one correct way to view any situation Personal background influences how we interpret events When the text states 'The community proved resilient, rebuilding not just their homes but their hope after the disaster,' what does this reveal about the concept of resilience? * 1 point Resilience encompasses both practical and emotional recovery Resilience is an innate trait that cannot be developed Resilience means avoiding all difficulties Resilience only involves physical recovery In analyzing 'The author's portrayal of the character's empathyâher ability to understand her enemy's pain even while fighting himâadded complexity to the conflict,' what does this suggest about empathy? * 1 point Empathy means agreeing with everyone Empathy makes people weak in conflicts Empathy should be avoided in difficult situations Empathy can coexist with opposition and create moral complexity When examining 'The character's integrity was tested when telling the truth would hurt people she loved,' what does this reveal about integrity? * 1 point Integrity means always following rules regardless of consequences Integrity means never causing any harm to others Integrity is only important in public situations Integrity involves making difficult moral choices even when costly In 'The student learned to advocate for her ideas by presenting evidence rather than just stating opinions,' what critical skill is being developed? * 1 point Supporting positions with logical reasoning and evidence Avoiding controversial topics entirely Learning to argue loudly and persistently Always agreeing with authority figures If you rewrote a scene from 'The Birchbark House' from Omakayas's grandmother's first-person perspective instead of Omakayas's, how would this most likely change the reader's understanding? * 1 point Nothing would change since they're both female characters The language would become more formal and difficult The story would become less interesting because adults are boring Readers would gain wisdom from experience but lose the innocence of childhood discovery In a plot diagram, the rising action serves which critical purpose beyond simply building toward the climax? * 1 point To provide background information about the setting To confuse readers so the ending is surprising To develop character relationships and establish stakes that make the climax meaningful To make the story longer and more detailed When analyzing the falling action in 'The Birchbark House,' which element would be most important to consider when writing an alternate version? * 1 point Whether the consequences of the climax align with the new direction you want the story to take Making sure it's shorter than the rising action Including a moral lesson for readers How quickly the conflicts get resolved In the exposition of a story, conflict serves which essential function that many readers don't realize? * 1 point To immediately grab attention with action scenes To provide comic relief before serious events To show off the author's writing skills To establish what the characters characterization/personality, which determines what they' must learn to overcome as they face more problems
Electrostatics The section of CBSE Class 12 Physics electrostatic potential and capacitance notes mainly deals with the in-depth analysis of electromagnetic phenomena when they are not performing any movements. Additionally, it is divided into ten further sub-topics to study the companion processes of reaching the state. These are - 1. Electric charge In this section of Physics ch 2 Class 12 notes, you get to learn about the basic features of electric charge and its expression in Physics. Along with its basics, the sections help to understand the full potential of charge. Different aspects of Charge included in Class 12 Physics Chapter 2 notes are - Definition Type: Positive and Negative Charge Unit and dimensional formula Point Charge Properties of Charge Comparison of Charge and Mass Methods of Charging Electroscope 2. Coulomb's Law Force is created when charges of opposite signs attract each other, and they repulse if the signs are the same. Coulomb's law tries to define this phenomenon through a mathematical formula, explicitly mentioned in Physics Class 12 notes Chapter 2. Moreover, there is key information about the variation of the constant k and its effect on a medium. Coulomb's law's vector form and the principle of superimposition are also explained in ch 2 Physics Class 12 notes. (Image will be uploaded soon) 3. Electric Field As stated in Class 12 Physics Chapter 2 notes, every positively or negatively charged particle has their respective electric fields. It feels a force at the time of interaction which might be attraction or repulsion. As it arises from electric charge, it is crucial to know about its different parts like - Electric field intensity Relation between electric force and electric field Super imposition of electric field Point charge Continuous charge distributions Properties of Electric Field Lines Motion of Charged Particles in an Electric field Learning more about the electric field from electric potential and capacitance notes Class 12 helps a student to get a grasp of upcoming chapters. 4. Electric Potential Energy When energy helps a charge to move from an electric field, it is known as the Electric Potential Energy. This section of electrostatic chapter Class 12 notes requires a student to study the Electron volt (eV), and the potential energy that an n number of charges can hold. 5. Electric Potential This section of Class 12 Physics Chapter 2 notes focuses on in-depth learning of Electric Potential or Voltage. Basically, it defines the potential movement of energy. 6. Relation between Electric Field and Potential Apart from knowing more about the relationship between the two values, Physics Class 12 Chapter 2 notes also discuss equipotential surfaces. 7. Electric Dipole Essentially, 'Dipoles' are two opposite points of charge represented with q and âq, with their distance between each other being 2a. Electric Dipoles are crucial in your study of Physics Class 12 Chapter 2 notes to learn more about electric fields and their potential. Additionally, Class 12 Physics Chapter 2 notes focus on the influence of electric dipoles on a uniform electric field mainly through Force and Torque, Work, and Potential Energy. In the last part of Electrostatics, further focus is on using the formulas to their fullest potential. It includes subsections of Electric Field, Electric Potential Energy, Electric Potential, and Electric Dipole. In the notes for electrostatic potential and capacitance, you will find proper solutions accompanied by clear and crisp diagrams for better understanding. 8. Gauss's Law Apart from just discussing the Gauss's Law, in Physics Class 12 ch 2 notes there is a thorough explanation of its properties and applications. The Gauss' Law states that net electric flux passing through a hypothetical closed surface is equal to the net electric charge present within the same closed surface. Being a broad part of the whole chapter, you may need to spend a little more time on it. Moving forward, it starts discussing the properties of conductors in relation to Gauss's Law. The Class 12 Physics notes Chapter 2 perfectly defines the journey to Gauss' Law from Coulomb's Law. Here is the Gauss's Law present in the Class 12 Physics ch 2 notes, (image will be uploaded soon) 9. Capacitors There is a dedicated section about Capacitors in the Class 12 Physics Chapter 2 notes elucidating its functions and importance as storage of potential electric energy. After explaining the structure of a capacitor, it points out the different types, parallel plate, spherical and cylindrical. The section of Chapter 2 notes of Physics Class 12 is further divided into subheads like: Properties of an ideal battery Grouping of capacitors Simple circuits (Series and Parallel) Dielectric Van de Graaff generator Combination of drops Charge distribution method Wheatstone Bridge-based circuit Extended Wheatstone Bridge Infinite network of capacitors Redistribution of charge between two capacitors Vedantu prepares the Class 12 Physics Chapter 2 notes with help from subject matter experts. In the PDF, you get a comprehensive idea of the topic along with potential answers to the most asked questions. Furthermore, the detailed explanation on each section and subsections are written in a simple language allows a student to ace their exams with wholesome knowledge. These Physics Chapter 2 Class 12 notes are going to be one of the best supplementary study materials besides a studentâs textbooks. Visit the Vedantu website or download the app to get your hands on all important notes! Important Questions A charge of 4 Ă 10â8C is uniformly distributed on the surface of a spherical conductor, having a radius of 15 cm. Determine the electric field just outside this sphere at a point that is 15 cm from the centre of this sphere. Determine the capacitance given that the distance between the two plates has been reduced by half and the parallel plate capacitor holds a capacitance of 20 pF (where 1pF = 10-12 F) having air between the two plates. What will be the total capacitance of a combination where three capacitors, each having a capacitance of 20 pF, are connected in series. A square having a side of 10 cm has a 500 ”C charge at its centre. Determine the work done to move a charge of 10 ”C between two points that are diagonally opposite each other on the square. At an equatorial point, what will be the electrostatic potential because of an electric dipole? Calculate the work done to move a test charge, q, through a length of 1 cm along the equatorial axis of an electric dipole? Polarisation A capacitor has its plates enclosed in a medium that can be filled by insulating substances. A net dipole moment is then induced by an electric field in the dielectric. This event causes the field in an opposite direction. Equipotential Surface An equipotential surface is a type of surface where the potential always has a constant value. If considered as a point charge, the concentric spheres that are centred at a particular area of this charge are basically equipotential surfaces. Advantages of Vedantu's Revision Notes: A Comprehensive Resource for Effective Learning There are several reasons why one may refer to Vedantu's revision notes for studying a subject like Electrostatic Potential and Capacitance. Here are some key points: Comprehensive Coverage: Vedantu's revision notes provide a comprehensive coverage of the entire topic, ensuring that all important concepts and subtopics are included. Concise and Organized: The notes are designed to be concise, focusing on the key points and core ideas. They are organized in a structured manner, making it easy for students to navigate and revise the content. Simplified Explanation: The revision notes offer simplified explanations of complex concepts, making them more accessible and easier to understand. This helps students grasp the material more effectively. Key Formulas and Equations: The notes highlight the key formulas and equations relevant to the topic, ensuring that students have a clear understanding of the mathematical aspects of Electrostatic Potential and Capacitance. Examples and Illustrations: Vedantu's revision notes often include examples and illustrations that help clarify concepts and provide practical applications, enabling students to better relate theory to real-world scenarios. Quick Recap: The revision notes serve as a quick recap of the important points, allowing students to review the material efficiently before exams or assessments. Exam-Oriented Approach: Vedantu's revision notes are designed with an exam-oriented approach, focusing on the topics and concepts that are frequently asked in examinations. This helps students prepare effectively and increase their chances of scoring well. 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HEALTH EDUCATION 3. SPECIFIC OBJECTIVES: Students should able to know about_______ 1. definition of health education 2. aims of health education 3. objectives of health education 4. principles of health education 5. scope of health education 6. planning of health education 7. steps in planning health education 8. levels of health education 9. doctors s responsibility 4. INTRODUCTION: Health education is a term frequently used by health care professional. its aims at individual and community health. Health education is the translation of what is known about health into desirable individual and community behaviour pattern by means of an education process. Definition: âA process aimed at encouraging people to want to be healthy , to know how to stay healthy, to do what they can individually and collectively to maintain health And seek help when neededâ. OBJECTIVES - To inform people or disseminate scientific knowledge about prevention of disease and promotion of health - To motivate people to change their habits and lifestyle that are harmful to their health also motivate people to adopt habits and ways of living conducive to healthy living. - To guide the people who need help to adapt and maintain healthy practices and lifestyle by showing proper community resources. --- PRINCIPLES OF HEALTH EDUCATION - Credibility Of Message: It is the degree to which the message to be communicated is perceived as trustworthy by the receiver. - Creating interest among participants: It is a psychological principle that people are unlikely to listen to things that are not of their interest. If a health programme is based on the felt needs, people will participate in the programme willingly. - Motivating the participants: Motivation is like a petrol engine that drives the mental engine. It is the fundamental desire in every person to learn. Motivation is contagious; one motivated person may spread motivation throughout the group. 13. - Enhance comprehension of content: It means health education should be based on the level of understanding, education and literacy of people at whom the teaching is directed. Teaching should be within the mental capacity of the audience. - Ensure reinforcement: Repetition at intervals is necessary to promote learning. Without reinforcement and feedback, students can go back to the pre-awareness stage. - Encourage active participation: Health education should aim at encouraging people to work actively with health workers and others in identifying their own health problems and also in developing solutions. 14. - Learning by doing: Teaching is effective when individuals actively participate in health education. Learning becomes active and quicker if the individuals are made active physically as well as psychologically. - Known to unknown: The people in a community know something and the health educator enlarges this knowledge. If the health educator links new knowledge with the old knowledge, it can enhance learning. - Maintaining good human relations: Sharing of information, ideas and feelings happens most easily between people who have a good relationship. 15. - Setting an example: The health educators should set a good example in the topic they are dealing with as it fosters better understanding. - Regular feedback: Feedback is one of the key concepts of the system approach. The health educator can modify the elements of the system in light of the feedback from his audience. For effective communication, feedback is of paramount importance - Efficient leadership: Leaders are agents of change and they can be made use of in health education work. Psychologists have shown and established that we learn best from people we respect and regard. 16. The essential attributes of a leader are as follows - Understands the needs of the community. - Provides proper guidance. - Takes initiative. - Is receptive to the views and suggestions of people. - Identifies himself with the community. Is selfless, honest, impartial, considerate and sincere. - Is easily accessible to people. 17. SCOPE OF HEALTH EDUCATION 1. Nutrition 2. Hygiene 3. Family health 4. Disease prevention and cantrol 5. Psychological health 6. Prevention of accident 7. Use of health services 8. Human biology 19. - Nutrition: The aim of nutrition education is to guide people to choose optimum and balanced diets, remove prejudices and promote good dietary habits. nutrition education is a major intervention for the prevention of malnutrition, promotion of health and improving the quality of life. 20. - Hygiene: This has two aspects: personal and environmental. Personal: The aim of personal hygiene is to promote standards of personal cleanliness . Environmental: Has two aspects: Domestic and community. All environmental sanitation programmes should include health education 21. - Family health: The family is the first defence as well as the chief reliance for the well-being of its members. One of the main tasks of health education is to promote family self-reliance, especially regarding the family's responsibilities in child bearing, child rearing, self-care and in influencing their children to adopt a healthy lifestyle. 22. - Disease prevention and control: Drugs alone will not solve health problems. Without health education, a person may fall sick again and again from the same disease. Educating the people about the prevention and control of locally endemic diseases is the first of the eight essential activities in primary health care. 23. - Psychological health: Psychological health problem can occur everywhere. There is a tendency to an increase in the prevalence of psychological diseases when there is a change in society from agriculture to an industrial economy and when people move from the warm intimacy of a village. 24. - Prevention of accidents: Accidents are a feature of the complexity of modern life. Accidents can occur in home, road and place of work. The predominant factor in accidents is carelessness that can be tackled by health education. 25. - Use of health services: Many people, particularly in rural areas, do not know what health services are available and many more do not know. There is a communication gap between the public and state health administration in the form of feedback for further improvement of health services. One of the declared aims of health education is to inform people about the health services available in their community. 26. PLANNING FOR HEALTH EDUCATION planning: is the process of making thoughtful and systemic decision about what needs to be done , how it has to be done, by whom And with what sources. 27. Principles of planning health education 1) Focus on actual current needs and context of community: It is important that plans are made with the needs and context of the community in mind. Health education should try to understand what is currently happening in the community one works in. 2) Plan for basic needs and interest of the community: Consider the basic needs and interests of the community. If the local needs and interests are not kept under consideration, the plans may not be effective. 28. 3) Planning with actual beneficiaries of health education: Plan with the people involved in the implementation of an activity. If people are included in planning, they will be more likely to participate and the plan will be more likely to succeed. 4) Identify and use all relevant community resources: It is essential that the health educator identify all the relevant resources that are locally available which could be used for benefit of people receiving the health education. 29. 5) Follow principle of flexibility: Planning should be flexible, not rigid. One should be able to modify the plans when necessary. For example, you would have to change your priorities if a new problem needing an urgent response arose. 6) A realistic plan not hypothetical: The planned activity should be achievable and take into consideration the financial, personal resources available and time constraints. Planning must be realistic; do not plan unachievable activities. 30. Steps in planning health education Planning is a continuous process. It does not just happen at the start of project . Health education must be well planned to actually improve and promote individual, family and community health 31. - Needs assessment: Conducting needs assessment is the first and probably the most important step in any successful planning process. assessment is the process of identifying and understanding the health problems of the community and their possible causes. - Identify priorities: After identifying the needs and resources of the community, the next is to identify their priorities because each community may have several problems but the urgent have to be given top priority in health education. For example: goitre 32. - Set the goals and objectives: In planning the process of health education, setting goals and objectives is the third and most essential step because these goals and objectives serve as consciously thought baseline parameters to be achieved during health education. - Develop strategies: Prior to the implementation of the health education intervention one must plan, develop and evaluate the several alternative strategies to achieve the set goals and objectives of health education because each problem and target community is quite unique. 33. - Implementation: This is the core phase of the health education process which includes carrying out the planned strategies so that the set goals and objectives of health education may be achieved. - Monitor and evaluation: This is the final step of the planning process of health education where continuous monitoring as well as end evaluation is carried out to ensure the degree to which stated goals and objectives have been achieved. 34. LEVELS/APPROACH OF HEALTH EDUCATION 35. INDIVIDUAL LEVEL - Individual Approach: The health education must first create an atmosphere of friendship and allow the individual to talk as much as possible. In this individual teaching we can discuss, argue and persuade the individual to change his behaviour. But by this we can reach to a small population and who come in contact with us. Methods of individual health education 1) Home visit 2) Personal contact/ counselling 3) Personnel letters 36. 1) Home visit: A home visit is one of the best approaches for individual health education because it can become one of the best opportunities for health education with individuals and their families. Home visits are important to understand the real background of families, their living conditions and the environment in which they live. 37. 2) Personal contact/counseling : Personal contacts or counselling (one-to-one communication) is a helping process where one person explicitly and purposefully gives his or her time to assist people explore their situations and act on a solution. After this the counsellor needs to work together with the person to find solutions that are appropriate to their situation. 38. 3) personal letters: Personal letters may also be used for individual health education, where health educators may get an opportunity to dispatch letters or printed education material to the people in a target community. 39. GROUP LEVEL Group health education may be useful way to deliver health education massages in efficient manner. A well organized group permits sharing of experiences and skills so that people are able to learn from each other. 40. Methods of group discussion 1)Lecture method: (Chalk & Talk ) A lecture may be defined as carefully prepared oral presentation of facts organized thoughts and ideas by a qualified person. The group should not be more than 30 and talk should not exceed 15-20 minutes. By using suitable audiovisual aids. 2) Group discussion: A group is an aggregation of people interacting in a face to face situation. It is a very effective method of health communication. 41. 3) Demonstration: A demonstration is a carefully prepared presentation to show how to perform a skill. This procedure is carried out step by step before an audience. 4) Panel discussion: In a panel discussion 4-8 qualified persons talk about the topic. Sit and discuss a given topic in front of a large group/audience. The chairman opens the meeting. Panel comprises of a chair person and 4-8 speakers. After the main aspect of the subject are explored, the audience is invited to take part. 42. 5) Symposium: It is a series of speeches on a selected subject. Each expert person present it briefly and at the end of session the chair person make a comprehensive summary. Audience are allowed to raise question. 6) Workshops : It consists of series of meetings usually 4 or more with emphasis on an individual work, within the group and with the help of consultants and response personnel. 7) Role play: This is a brief acting out of an actual situation for the benefit of the audience for better understanding. 43. 8) Conference and seminars: This programmes are usually held on a regional, state/national level. Where several experts from different disciplines meet to deliberate on a particular theme, to appraise others of latest knowledge and research in a particular field. 9) Open forum: It refers to the public meeting which are held for various purposes in the community, for example: gram sabha 44. COMMUNITY LEVEL It is meant for a defined community and is not only to create awareness but also to help people understand their health problems and needs, find alternatives solutions to their problems and needs , implement them, evaluate and get feedback and accordingly do the needful. For health education at the community level, it is better to approach local leaders who are influential and who have the peopleâs confidence. These may include local officers such as gramsevak, panchayat sarpanch ,police officer or block development officer etc . 45. HOSPITAL LEVEL 1) Health Education in OPD/Outdoor: The patient and his attendants have to spend a lot of time in the outpatient department for health check-up, treatment, registration, diagnosis, admission procedure etc. This period can be utilised for health education. For this, the following means/devices can be used: - Exhibiting pictures, posters, charts, bulletin board and models in the waiting hall. - Arranging group discussion, slide show, or documentary film in a proper place and on a proper topic. - Giving health education on a personal level in the consulting room. This mainly includes nutrition clinic, family planning clinic, psychiatric clinic etc. 46. - Distributing pamphlets. - Arranging street plays or nukkad naatak in the outpatient department or its neighbourhood. 47. 2) Health Education in wards/ IPD: While taking care of the patients the indoor patients, doctors s have the opportunities to educate them. This period can be fully utilised to give health education to the patients. For this the following methods can be effective: - Conversation with the patient and motivating him for change in his behaviour. - Imparting health education by arranging live demonstration for nutrition, treatment, diagnosis etc. - Providing clinical or bedside teaching. - Providing incidental teaching to patient and his attendants. 48. - Presenting examples. To describe the gains of health education in an individual suffering from the same health education in an individual suffering from the same disease and arranging a meeting between the patient and the cured old patients.