Approach to the Unique Care of Adolescents - PowerPoint PPT Presentation

Loading...

PPT – Approach to the Unique Care of Adolescents PowerPoint presentation | free to download - id: 708cca-Mjc3M



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Approach to the Unique Care of Adolescents

Description:

Approach to the Unique Care of Adolescents Charles E. Irwin, Jr., M.D. Department of Pediatrics Division of Adolescent and Young Adult Medicine UCSF Benioff Children ... – PowerPoint PPT presentation

Number of Views:197
Avg rating:3.0/5.0
Slides: 64
Provided by: BenP153
Learn more at: http://nahic.ucsf.edu
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Approach to the Unique Care of Adolescents


1
Approach to the Unique Care of Adolescents
Charles E. Irwin, Jr., M.D. Department of
Pediatrics Division of Adolescent and Young Adult
Medicine UCSF Benioff Childrens
Hospital University of California, San Francisco
July 2013
2
I see no hope for the future of the world if
they are dependent on the frivolous youth of
today , for certainly all youth are reckless
beyond words. When I was a boy we were taught to
be respectful of elders but the present youth are
exceedingly wise and impatient of restraint.
Hesiod, 8th Century B.C.
3
I would there were no age between ten and
three-and-twenty, or that youth would sleep out
the rest, for there is nothing in the between but
getting wenches with child, wronging the
ancientry, stealing, fighting...
The Winters Tale, Shakespeare
4
The grain of heedlessness
The time from the 18th to the 24th year is best
suited to military service. The body is then
quite vigorous enough to endure hardships, and
the soldier is as yet free and unfettered. The
grain of heedlessness, a quality peculiar to the
freshness of youth, is an excellent incentive to
martial achievement
Baron Colmar von der Goltz The Nation in Arms 1883
5
  • Until recently, the pediatrician has been
    preoccupied with premature babies, transfusions,
    feeding problems, running ears The internist has
    also been busy with the ills of adulthood and
    advancing age and has still to come to the period
    of adolescence. Yet this field is particularly
    important, marking as it does the transition from
    boy to man and from girl to woman.
  • - James Roswell Gallagher

Gallagher, 1954.
6
Granville Stanley Hall 1844 - 1924
  • Adolescence its psychology and its relation
    to physiology, anthropology, sociology, sex,
    crime, religion and education (1904)

7
March 2007
April 2012
8
(No Transcript)
9
Adolescent Health
Substance use
Accidents injury
Mental health well being
Sexual health
Chronic illness
Obesity eating disorders
Prevention - early intervention - clinical care
10
Brain Development
  • Grey matter volume peaks in early adolescence
  • Selective pruning proceeds from back to front
  • Greater efficiency of neurotransmission results
    from myelination
  • Neuromaturation underpins emotional regulation
    control

11
A Model of Development
Late adolescence 20-24 yrs
Early adolescence 10-14 yrs
Mid adolescence 15-19 yrs
Maturation of brain facilitates regulatory
competence
Period of heightened vulnerability to risk
taking, problems in terms of affect behaviour
Puberty heightens emotional arousability,
sensation-seeking, reward orientation
Steinberg
12
Biopsychosocial Development During Adolescence/
Emerging Adulthood Early Adolescence (Age 10 14
Years)
Characteristics Impact
1) Onset of puberty, becomes concerned with developing body. Questions concerning normality of physical maturation, stages of development and how process relates to peers of same gender. Important to normalize differences.
2) Begins to expand social relationships beyond family. Encourage teens to begin to take responsibility for own health - in consultation with parents. Begin time alone with patient.
3) Begin transition from concrete to abstract thinking. Continue anticipatory guidance to parents add prevention education for teen. Concrete thinking requires straight forward explicit messages.
13
Biopsychosocial Development During Adolescence/
Emerging Adulthood Middle Adolescence (Age 14
18 years)
Characteristics Impact
1) Pubertal development usually complete, sexual drives emerge. Explores ability to attract others. Sexual experimentation (same and opposite sex) begins.
2) Peer group sets behavioral standards, family values usually persist. Peer group influences engagement in positive and negative health behaviors peers offer key support. Emphasize making good choices and taking responsibility.
3) Conflicts over independence. Increased assumption of independent action, with desire for parental support/ guidance. Encourage negotiation. Increase involvement of teen in setting health goals how to manage health situations. Reinforce adolescents growing competencies.
4) Emergence of abstract thinking with new cognitive competencies. Increased ability to process information and reflect. Leads to questioning adult behavior. May consider broader range of possibilities/options, but not able to integrate into real life.
14
Biopsychosocial Development During Adolescence/
Emerging Adulthood Late Adolescence/Emerging
Adulthood (Age 18 24 Years)
Characteristics Impact
1) Physical maturation complete. Body image and gender role definition clearer. Begins to feel comfortable with relationships and decisions regarding sexuality and preference. Individual relationships become more important than peer group.
2) Individuals less ego-centric able to understand others. More open to questioning regarding behavior. More able to work with clinician on setting goals and changing behavior.
3) Idealistic Idealism may lead to conflict with family or authority figures.
4) Identity Exploration/Life roles begin to be defined Interested in discussion of life goals how they impact health.
5) Cognitive development nearing completion Most are capable of understanding a full range of options for health issues. Important to help them become competent in negotiating the health care system.
15
Tips on Development
  • Early - be very specific focus on youths
    concerns be on alert for early developers
    counsel parents
  • Middle trusting friendly relationships are key
    concrete still best emphasize adult connections,
    health promotion harm reduction support/advise
    parents.
  • Late - abstract reasoning - understanding
    consequences of actions include partners in
    office visits transition planning

16
The Clinical Visit
17
Structure of Visit
  • Elicit Concerns of Adolescent/Family
  • Discuss How visit will go
  • Use Development to guide process
  • Time alone depending on cultural norms
  • Physical Exam guided by concerns
  • Feedback to Adolescent and Family at conclusion

18
HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Home
Education
Eating
Activities
Drugs
Sexuality
Suicidality
Strengths
19
HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Home How is the adolescent's home life? How are his/her relationships with family members? Where and with whom does the patient live? Is his/her living situation stable?
Education (or Employment) How is adolescent's school performance? Is he/she well-behaved, or are there discipline problems at school? If he/she is working, is he/she making a living wage?
Eating (incorporates body image) Does patient have a balanced diet? Is there adequate calcium intake? Is the adolescent trying to lose or gain weight, and (if so), is it in a healthy manner? How does he/she feel about his/her body? Has there been significant weight gain/loss recently?
20
HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Activities How does patient spend his/her time? Are they engaging in dangerous or risky behavior? Are they supervised during their free time? With whom do they spend most of their time? Do they have a supportive peer group?
Drugs (including alcohol and tobacco) Does the patient drink caffeinated beverages (including energy drinks)? Does the patient smoke? Does the patient drink? Has the patient used illegal drugs? If there is any substance use, to what degree, and for how long?
21
HEEADSSS ASSESSMENT for Psychosocial Concerns
Screening History
Sexuality Is the patient comfortable with his/her sexual development? Have they had a sexual relationship? Does the patient get routine reproductive health checks? Are there any symptoms of a sexually transmitted infection? Does the patient have questions about sexual behavior?
Suicidality (including general mood assessment) What is the patient's mood from day to day? Has he/she thought about/attempted suicide?
Strengths Inquire about assets.
22
Recommendations for Adolescent Preventive Health
Care
Age 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
History (initial/interval) X X X X X X X X X X X
Measurements
Height and weight X X X X X X X X X X X
Body Mass Index X X X X X X X X X X X
Blood Pressure X X X X X X X X X X X
Sensory Screening
Vision X X X
Hearing
Development/Behavioral Assessment X X X X X X X X X X X
Psychosocial/Behavioral Assessment
Alcohol Drug Use Assessment
Physical Examination X X X X X X X X X X X
Procedures
Immunization X X X X X X X X X X X
Hematocrit or Hemoglobin
Tuberculin Test
Dyslipidemia Screening ?
STI Screening
Cervical Dysplasia Screening
Anticipatory Guidance X X X X X X X X X X X
X To be performed Risk assessment to be
performed, with appropriate action to follow
? Range during which a service
may be provided with the symbol indicating the
preferred age
23
Recommendations for Adolescent Preventive Health
Care
Age1 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
History (initial/interval) X X X X X X X X X X X
Measurements
Height and weight X X X X X X X X X X X
Body Mass Index X X X X X X X X X X X
Blood Pressure X X X X X X X X X X X
Sensory Screening
Vision X X X
Hearing
X To be performed Risk assessment to be
performed, with appropriate action to
follow Adapted from Hagan JF, Shaw JS, Duncan PM.
Bright Futures Guidelines for Health Supervision
of Infants, Children, and Adolescents, 3rd Ed.
Elk Grove Village IL American Academy of
Pediatrics, 2008.
24
Recommendations for Adolescent Preventive Health
Care
Age1 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
Development/ Behavioral Assessment X X X X X X X X X X X
Psychosocial/ Behavioral Assessment
Alcohol Drug Use Assessment
Physical Examination2 X X X X X X X X X X X
X To be performed Risk assessment to be
performed, with appropriate action to
follow Adapted from Hagan JF, Shaw JS, Duncan PM.
Bright Futures Guidelines for Health Supervision
of Infants, Children, and Adolescents, 3rd Ed.
Elk Grove Village IL American Academy of
Pediatrics, 2008.
25
Recommendations for Adolescent Preventive Health
Care
Age1 11 y 12 y 13 y 14 y 15 y 16 y 17 y 18 y 19 y 20 y 21 y
Procedures
Immunization3 X X X X X X X X X X X
Hematocrit or Hemoglobin4
Tuberculin Test5
Dyslipidemia Screening6 ?
STI Screening7
Cervical Dysplasia Screening8
Anticipatory Guidance9 X X X X X X X X X X X
X To be performed Risk assessment to be
performed, with appropriate action to follow ?
Range during which a service may be
provided with the symbol indicating the preferred
age
Adapted from Hagan JF, Shaw JS, Duncan PM. Bright
Futures Guidelines for Health Supervision of
Infants, Children, and Adolescents, 3rd Ed. Elk
Grove Village IL American Academy of
Pediatrics, 2008.
26
1Age if an adolescent/young adult comes under
care for the first time at any point on the
schedule, or if any items are not accomplished at
the suggested age, the schedule should be brought
up to date at the earliest possible time. 2At
each visit, age-appropriate physical examination
is essential. 3Schedules per the Committee on
Infectious Diseases, published annually in the
January issue of Pediatrics. Every visit should
be an opportunity to update and complete an
adolescents immunization. 4See AAP Pediatric
Nutrition Handbook, 5th Edition (2003) for a
discussion of universal and selective screening
options. 5Tuberculosis testing per
recommendations of the Committee on Infectious
Diseases, Testing should be done on recognition
of high-risk factors. 6Third Report of the
National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III) Final Report (2002)
URLhttp//circ.ahajournals.org/cgi/content/full/
106/25/3143 and The Expert Committee
Recommendations on the Assessment, Prevention,
Treatment of Child and Adolescent Overweight and
Obesity. Supplement to Pediatrics. In press.
7All sexually active patients should be screen
for sexually transmitted infections (STIs). 8All
sexually active girls should have screening for
cervical dysplasia as part of a pelvic
examination beginning within 3 years on onset of
sexual activity or age 21 (whichever comes
first). 9Refer to the specific guidance by age
as listed in Bright Futures Guidelines.
27
Physical Examination
  • General Appearance
  • Vital Signs
  • Affect, Mood, Dress, Energy Level
  • BMI, VS, BP, Orthostatics if low BMI, Audiogram,
    Visual Acuity

28
BMI
  • Assess height and weight EVERY visit
  • Calculate BMI
  • Look for trends
  • Consider the context of growth and development
  • Record on the appropriate Growth/BMI chart

29
BMI Charts 2-17 year olds
30
Physical Exam, cont.
  • Skin
  • Breasts
  • Lymph nodes
  • Chest/Cardiovascular
  • Rectal
  • GU
  • Acne, striae, cuts
  • Tanner stage, BSE
  • Palpate for size
  • Palpation/Auscultation
  • Symptomatic GI/GU
  • Tanner/SMR Staging

31
Physical Exam, cont.
  • Genitalia, Males
  • Genitalia, Females
  • Teach Testicular Self Exam R/O
  • Pelvic if indicated

32
PUBERTY
33
(No Transcript)
34
Sequence of Pubertal Events
Height Spurt FEMALES MALES Breast Development
Menarche Female Pubic Hair Male Public Hair
Testicular Volume
2
3
4
5
2
5
4
3
5
4
3
2
gt4
10
16
9 10 11 12 13 14 15 16
35
Timing of Pubertal Onset--Females
  • Timing of onset is variable
  • Average age of onset of breast development is 8.9
    years in African American girls and 9.9 years in
    white girls. Average age of onset of breast
    development for Mexican American girls appears to
    be in between.

Herman-Giddens, 1997
36
Sequence of Pubertal Events--Females

Breast bud
Pubic hair
Peak height velocity
Menarche
37
Tanner Staging--Females
  • Breast staging
  • Pubic hair staging

Marshall WA, Tanner JM. Variations in the Pattern
of Pubertal Changes in Girls. Arch Dis Child.
196944(235)291-303. http//www.ncbi.nlm.nih.gov
/pmc/articles/PMC2020414/
38
Timing of Pubertal Onset--Males
  • Timing of onset is variable
  • Average age of onset is 11.6 years (range 9.5 to
    14 years).
  • Onset appears to be earliest in African American
    males, latest in white males. Hispanic males are
    in between.

Herman-Giddens, 2012.
39
Sequence of Pubertal Events--Males
  • 1.
  • 2.
  • 3.

Testicular enlargement
Sexual hair, phallic and scrotal changes
Peak height velocity
40
Tanner Staging (Sexual Maturity Ratings)--Males
  • Genital staging
  • Pubic hair staging

Marshall WA, Tanner JM. Variations in the Pattern
of Pubertal Changes in Boys. Arch Dis Child.
197045(239)13-23. http//www.ncbi.nlm.nih.gov/p
mc/articles/PMC2020414/
41
Sequence of Pubertal Events
Height Spurt FEMALES MALES Breast Development
Menarche Female Pubic Hair Male Public Hair
Testicular Volume
2
3
4
5
2
5
4
3
5
4
3
2
gt4
10
16
9 10 11 12 13 14 15 16
42
Height Spurt
  • 25 of adult height is accounted for during
    pubertal growth
  • Growth spurt in females
  • at average age of 11.5
  • average Tanner stage of 2-3
  • peak velocity of 8.3 cm/year
  • Growth spurt in males
  • at average age of 13.5 years
  • average Tanner stage of 4
  • peak velocity of 9.5 cm/year

43
Pubertal timing and behavior
  • Early pubertal timing
  • In females associated with poor self esteem and
    negative body image. Associated with early onset
    of sexual activity and older partners.
  • In males associated with early onset of sexual
    activity, but socially desirable.
  • Late maturity
  • In males associated with poor self-esteem and
    negative body image
  • MEDIATORS?
  • Actual timing?
  • Perceived timing?

44
Puberty great opportunity for education
  • Growth Spurt 25 of adult height is accounted
    for during pubertal growth
  • Changes in Body Shape and Size
  • Voice Change
  • Acne
  • Body Odor
  • Menarche Menses
  • Spermarche Ejaculation
  • Vital Sign Changes
  • Bone MASS

45
Questions Concerning Puberty by Early Adolescents
Females (n 114) Males (n 94)
General puberty 13 11
Growth 6 9
Nongenital characteristics 4 5
46
Questions Concerning Puberty by Early Adolescents
Females (n 114) Males (n 94)
General anatomy 10 15
General physiology 33 18
Sexuality/reproduction 25 27
Psychosocial aspects 7 5
Ryan, Millstein, Irwin. J Adol Health (1996)
47
C
  • Youth-friendly care services

48
General Principles of Adolescent Health Care
Delivery
  • Availability
  • Accessibility
  • Approachability
  • Acceptability
  • Appropriateness

49
General Principles in Working with Teens
  • Rapport and respect are key
  • Review the parameters of your relationship,
    encounters, discussions up front AND on a regular
    basis
  • Use their developmental stage and interact with
    them accordingly
  • Seize every opportunity
  • Be up front genuine express your concerns

50
General Principles of working with teens
  • Assess strengths assets as well as risks
    problems
  • Reinforce and bolster connections
  • Educate about mind-body connection
  • Engage and support family during adolescence
  • Be Authoritative

51
Some common findings to address
  • Acne
  • Gynecomastia in males
  • Irregular menses
  • Poorly controlled chronic problems
  • Eczema
  • Asthma
  • Allergic rhinitis

52
Dont forget!
  • Adolescent morbidity and mortality is PRIMARILY
    behaviorally related
  • Rarely will you find a physical problem that
    hasnt been illuminated by the history
  • INVEST YOUR TIME AND EFFORT IN THE PSYCHOSOCIAL
    ASSESSMENT AND COUNSELING!

53
The 5 As for Brief Office Based Interventions
Ask Determine the presence of the behavior.
Advise Deliver a clear, personalized message about the need to change the behavior.
Assess willingness to change Determine whether the adolescent is prepared to change his or her behavior.
Assist the behavior change Determine short-term, concrete actions to make the behavior change set behavioral goals. Provide adjunct therapy as appropriate (e.g., nicotine replacement for tobacco cessation).
Arrange follow-up Schedule a follow-up visit or phone call soon after the date set for the behavior change, ideally within 1 week.
54
It has been frequently said that adolescence is
the neglected age group perhaps it is more sound
to say that it is physicians' training in the
care of adolescents which has been given
relatively little attention
JR Gallagher. Pediatrics 1957
55
Inadequate Training in Adolescent Health
  • US primary care physicians (Blum 1990)
  • 45 insufficient training is major barrier
  • Australian general practitioners (Veit 1995)
  • 80 inadequate undergraduate training
  • 87 interested in further training
  • Swiss primary care doctors (Kraus 2003)
  • 62 interested in further training

56
Postgraduate medical training agenda
Primary care
Adult medicine
Core skills, attitudes knowledge
Psychiatry
Pediatrics
Obstetrics gynecology
An integrated approach to clinical skills
development for adolescent health
Sawyer et al, 2007
57
Make Adolescent Health Visible
  • Academic leadership
  • Research
  • Clinical capacity building
  • Policy

58
Society for Adolescent Health and Medicine
  • The Society for Adolescent Health and Medicine
    (SAHM) is the only national organization (with
    members from 30 countries worldwide) dedicated
    exclusively to advancing the health and
    well-being of adolescents
  • 111 Deer Lake Rd, Ste 100, Deerfield, IL 60015
  •  
  • Phone 1-847-753-5226, Fax 1-847-480-9282,
    info_at_adolescenthealth.org

59
References
  • Adolescent Health Supplement, The Lancet, March
    2007.
  • Blum R. (ed). Young people not as healthy as
    they seem. The Lancet 374 853-854, 2009.
  • Buckelew SM, Adams SH, Irwin CE, Jr. Gee S, Ozer
    E. Increasing Clinician Self-Efficacy for
    Screening Counseling Adolescents for Risky
    Behaviors Results of an Intervention. Journal of
    Adolescent Health 43198 200. 2008.
  • Committee on Infectious Diseases. Red Book
    Report of the Committee on Infectious Diseases.
  • DiClemente RJ, Santelli JS, Crosby RA (eds).
    Adolescent Health Understanding and Preventing
    Risk Behaviors. San Francisco Jossey-Bass, 2009.
  • Donahue WT, Benuto LT, Tolle LW (eds). Handbook
    of Adolescent Health Psychology
  • Duncan PM, Garcia Ac, Frankowski BL et al.
    Inspiring Healthy Adolescent Choices A Rationale
    for and Guide to Strength Promotion in Primary
    Care. Journal of Adolescent Health 41(6)525-535,
    2007.
  • Elster AB and Kuznets N (eds) AMA Guidelines for
    Adolescent Preventive Services(GAPS)
    Recommendations and Rationale. Baltimore, MD
    Williams and Wilkins 1994.
  • Giedd JN. The Teen Brain insights from
    neuroimaging. Journal of Adolescent Health
    42(4)335-343. 2008.
  • Gallagher JR. The adolescents unit of the
    Childrens Hospital Medical Center. Children
    1165, 1954.
  • Goldenring, JM and Rosen DS. Getting into
    adolescent heads An essential update.
    Contemporary Pediatrics, Vol 21 (1) 64 90,
    2004.
  • Hagan JF, Shaw J, Duncan PM (eds). Bright
    Futures Guidelines for Health Supervision of
    Infants, Children and Adolescents. American
    Academy of Pediatrics Elk Grove Village, Ill,
    2007.
  • Heyman RB, Gotlieb EM (eds) Whats New in
    Adolescent Clinical Care? Adolescent Medicine
    State of the Art Reviews. American Academy of
    Pediatrics Elk Grove Village, Ill. 20(1)1-259
    2009.

60
References
  • Herman-Giddens ME, Slora EJ, Wasserman RC, et al.
    Secondary sexual characteristics and menses in
    young girls seen in office practice A study from
    the Pediatric Research in Office Settings
    network. Pediatrics. 1997 99(4) 505-512.
  • 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.
  • Irwin, CE, Jr., Adams, SA, Park, JM, Newacheck
    PW. Preventive Care For Adolescents Few Get
    Visits, and Fewer Get Services. Pediatrics
    123e565 572. 2009.
  • Manley M, Epps RP, Husten C, et al Clinical
    Intervention in tobacco control. A National
    Cancer Institute Training Project for Physicians.
    JAMA 266 3176 3173, 1991.
  • National Research Council and Institute of
    Medicine. Adolescent Health Services Missing
    Opportunities. Committee on Adolescent Health
    Services and Models of Care for Treatment,
    Prevention, and Healthy Development. R.S.
    Lawrence, J. Appleton Gootman and L. J. Sims,
    Editors. Board on Children, Youth and Families,
    Division of Behavioral and Social Sciences and
    Education. Washington, D.C. The National Academy
    Press. 2009.
  • Neinstein LS, Gordon CM, Katzman, DK, Rosen DS,
    Woods ER. Adolescent Health Care A Practical
    Guide. Fifth Edition. Philadelphia Lippincott,
    Williams Wilkins. 2002.
  • Ozer EM, Adams SH, Lustig JL, Gee S, Garber A,
    Rieder Gardner L, Rehbein M, Addison L, Irwin CE,
    Jr. Increasing the screening and counseling of
    adolescents for risky health behaviors A primary
    care intervention. Pediatrics 115960-968. 2005.
  • Park MJ, Brindis CD, Chang F, Irwin CE, Jr. A
    midcourse review of the Healthy People 2010 21
    critical health objectives for adolescent and
    young adults. Journal of Adolescent Health 42
    329 334. 2008.
  • Park MJ, Mulye TP, Adams SH, Brindis CD, Irwin
    CE, Jr. The Health Status of Young Adults in the
    US. Journal of Adolescent Health 39 305-317.
    2006.
  • Paul T, Park J, Adams, SH, Brindis, CB, Irwin CE,
    Jr., Adolescent/Young Adult Health in the U.S.
    Trends Implications, Journal of Adolescent
    Health 45 8 24. 2009.
  • Patton GC, Coffey C, Sawyer SM. Global Patterns
    of mortality in young people a systematic
    analysis of population health data, The Lancet
    374 881-892, 2009.
  • Yu JW, Adams SH, Burns J, Brindis CD, Irwin CE,
    Jr. Use of Mental Health Counseling as
    Adolescents Become Young Adults. Journal of
    Adolescent Health 43 268 276. 2008.

61
(No Transcript)
62
Adolescent Health ,2007
  • Adolescence is a time in life that harbours many
    risks and dangers, but also one that presents
    great opportunities for sustained health and well
    being, The Lancet, 2007

63
March 2007
April 2012
About PowerShow.com