Perspectives on the role of the nurse ethicist.

This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between 'nurse ethicist' and 'clinical ethicist' is largely irrelevant. The second author describes the impact and value that a nurse in an ethics role plays, highlighting the 'tacit knowledge' and 'lived experience' they bring to clinical ethics consultation. However, the second author also warns that the 'nurse ethicist' must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as 'nurse ethicist' on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics.

Effect of Combining 0.01% Atropine with Soft Multifocal Contact Lenses on Myopia Progression in Children.

SIGNIFICANCE: Combining 0.01% atropine with soft multifocal contact lenses (SMCLs) failed to demonstrate better myopia control than SMCLs alone. PURPOSE: The Bifocal & Atropine in Myopia (BAM) Study investigated whether combining 0.01% atropine and SMCLs with +2.50-D add power leads to greater slowing of myopia progression and axial elongation than SMCLs alone. METHODS: Participants of the BAM Study wore SMCLs with +2.50-D add power daily and administered 0.01% atropine eye drops nightly (n = 46). The BAM subjects (bifocal-atropine) were age-matched to 46 participants in the Bifocal Lenses in Nearsighted Kids Study who wore SMCLs with +2.50-D add power (bifocal) and 46 Bifocal Lenses in Nearsighted Kids participants who wore single-vision contact lenses (single vision). The primary outcome was the 3-year change in spherical equivalent refractive error determined by cycloplegic autorefraction, and the 3-year change in axial elongation was also evaluated. RESULTS: Of the total 138 subjects, the mean ± standard deviation age was 10.1 ± 1.2 years, and the mean ± standard deviation spherical equivalent was -2.28 ± 0.89 D. The 3-year adjusted mean myopia progression was -0.52 D for bifocal-atropine, -0.55 D for bifocal, and -1.09 D for single vision. The difference in myopia progression was 0.03 D (95% confidence interval [CI], -0.14 to 0.21 D) for bifocal-atropine versus bifocal and 0.57 D (95% CI, 0.38 to 0.77 D) for bifocal-atropine versus single vision. The 3-year adjusted axial elongation was 0.31 mm for bifocal-atropine, 0.39 mm for bifocal, and 0.68 mm for single vision. The difference in axial elongation was -0.08 mm (95% CI, -0.16 to 0.002 mm) for bifocal-atropine versus bifocal and -0.37 mm (95% CI, -0.46 to -0.28 mm) for bifocal-atropine versus single vision. CONCLUSIONS: Adding 0.01% atropine to SMCLs with +2.50-D add power failed to demonstrate better myopia control than SMCLs alone.

Conflicts and con-fusions confounding compassion in acute care: Creating dialogical moral space.

BACKGROUND:: Compassion, understood as empathy for another who is experiencing physical, mental, emotional and/or spiritual suffering, is an essential element of our shared understandings of nursing and the constitution of the professional nurse. THEORETICAL FOUNDATION:: Charles Taylor account of ethics which concerns 'what or who is it good to be' rather than the predominant analytical moral philosophy approach which concentrates on 'what ought one to do' is the core concern of this discussion. An ontological appreciation of our shared human condition is the premise upon which the discussion is based. DISCUSSION:: This article proposes that concept by opening a dialogical space, nurses can engage in reflection and sense making wherein they explore individually and collectively the conflicts and confusions encountered in their day-to-day work. Through their dialogues, nurses - individually and collectively - orient and reorient themselves and each other towards what they see as meaningful and purposeful in their lives and in doing so they are well positioned to reaffirm their commitment to compassion as a value which both anchors and orients their day-to-day work. IMPLICATIONS:: The provision of opportunities in the workplace, in the form of dialogue, to articulate often unspoken assumptions and frameworks in which nursing work is carried out can not only initiate the building of pathways of support but also assist nurses reaffirm their compassion - arguably the essence of their nursing practice.

Mixing State of Carbonaceous Aerosols of Primary Emissions from "Improved" African Cookstoves.

Designs of "improved" stoves are introduced recently to benefit the solid fuel consumption of cooking activities in developing countries, but the uncertainties concerning the combustion processes and particulate emissions remain poorly characterized. To help understand this, combustion in three examples of "improved" African cookstoves was investigated in the laboratory. A typical European heating stove was included for comparison purpose. Detailed aerosol emissions were studied in real-time with an Aerosol Mass Spectrometer and Single Particle Soot Photometer, to explore interactions between black carbon (BC) and organic carbon aerosols, which were parametrized according to modified combustion efficiency (MCE), a common metric used within the atmospheric emission community. Greater than 50% of the total organic matter (OM) was found in BC-containing particles when MCE was >0.95 for dry oak and coal fuels, whereas at lower MCE, over 80% of the total OM for most of the fuels existed in particles without detectable BC. When the OM mass fraction of total particulate matter (PM1) > 0.9, the mass ratio of OM to refractory BC in BC-containing particles was about 2-3, but only ∼0.8 when OM mass fraction <0.9. These findings are not currently included in models and such information should be considered in the future emission scenarios.

Delivering compassionate care in intensive care units: nurses' perceptions of enablers and barriers.

BACKGROUND: Compassion is core to nursing practice. Nurses' expression of compassion is a complex interaction informed by the nurse, the patient and the practice environment. AIM: The aim of this study was to identify personal, professional and organizational factors, intensive care nurses, in a major metropolitan facility in Australia, identified as enabling or disabling them to be compassionate. DESIGN: Intensive care nurses (n = 171) reflected on their experiences during 'compassion cafés' conducted in 2015. METHOD: Qualitative, reflexive methods were used to explore ICU nurses' perceptions of enablers and barriers. Nurses documented their perceptions, which were thematically analysed. Meanings were subsequently verified with participants. RESULTS: The findings identified multiple factors both inside and outside the workplace that constrained or enabled nurses' ability to be compassionate. Two main factors inside the workplace were culture of the team, in particular, support from colleagues and congruency in work practices and decision-making, and connections with patients and families. Outside the workplace, nurses were influenced by their values about care and lifestyle factors such as family demands. CONCLUSIONS: Nurses capacity to be compassionate is a complex interplay between nursing knowledge and expectations, organizational structures and lifestyle factors. IMPLICATIONS: The responsibility for 'compassionate' care is a shared one. Nurses need to be cognizant of factors that are enabling or inhibiting their ability to be compassionate. Healthcare leaders have a responsibility to provide structural support (staffing, education and space) that assist nurses to deliver compassionate care and where appropriate cater for nurses needs so that they are better able to be compassionate.

Delivering healthcare information via the internet: cardiac patients' access, usage, perceptions of usefulness, and web site content preferences.

OBJECTIVES: To assess patients' usage of the Internet as a source of personal healthcare information and patients' perceptions of usefulness and content preferences of more locally focused online health-related material. MATERIALS AND METHODS: A paper-based survey was undertaken by a convenience sample of cardiac outpatients. Age, gender, Internet access, Internet usage, perception of usefulness of online information, predicted intention to use a local cardiology Web site if available, and preferred components to be included were recorded. Univariate and bivariate statistics were used. RESULTS: Two hundred thirty-seven patients responded (62.1% males). One hundred seventy-six (74.3%) used the Internet, with 126 (63%) using it daily. For patients who did not have direct access to the Internet, 26 (50%) had a family member to do this on their behalf. Thus, the majority of patients (202 [85%]) had access to the Internet at home or someone who could access it on their behalf. Internet usage declined with age (Kendall's tau_b=0.321, p<0.001). There was no difference in use with gender (p=0.235). There was considerable interest expressed in a locally delivered Web-based information service. CONCLUSIONS: Online healthcare information services have the potential to reach the vast majority of cardiac patients either directly or through family support. The most elderly patients are less likely to use these services. Despite apparent satisfaction with existing online resources, there appears to be an unmet need for more information and considerable support for a locally based cardiac patient Web resource to deliver this. These findings may help guide future patient information Web site redesign.

Uptake and speciation of Zn and Pb by Miscanthus grown in contaminated soils.

The uptake by and distribution of Zn and Pb within a novel seed-based Miscanthus hybrid grown in contaminated soil was assessed. Results from juvenile plants in a pot-trial was compared with data for mature biomass of the same species harvested during a field-trial. Both Zn and Pb uptake by juvenile plants were observed to increase in proportion to the soil concentrations. Both Zn and Pb accumulation differed between leaf and stem structures, and both were different in the mature biomass compared with juvenile plants. Analysis of X-Ray Absorption Fine Structures (XAFS) revealed different Zn speciation in stems and leaves, and differences in Zn speciation with plant maturity. Sulfur ligands consistent with the presence of cysteine rich metallothioneins (MT) and phytochelatin (PC) complexes were the dominant Zn species in juvenile plant leaves, together with octahedral O/N species typified by Zn-malate. Sulfur ligands were also prevalent in stems from juvenile plants, but predominant O/N speciation shifted towards tetrahedral coordination. In contrast, tetrahedral Zn coordination with O/N species predominated in the mature biomass crop. The XAFS spectra for the mature biomass were consistent with Zn being retained within cell walls as pectin and/or phosphate complexes.

Peripheral Defocus, Pupil Size, and Axial Eye Growth in Children Wearing Soft Multifocal Contact Lenses in the BLINK Study.

Purpose: The purpose of this study was to evaluate the relationship between peripheral defocus and pupil size on axial growth in children randomly assigned to wear either single vision contact lenses, +1.50 diopter (D), or +2.50 D addition multifocal contact lenses (MFCLs). Methods: Children 7 to 11 years old with myopia (-0.75 to -5.00 D; spherical component) and ≤1.00 D astigmatism were enrolled. Autorefraction (horizontal meridian; right eye) was measured annually wearing contact lenses centrally and ±20 degrees, ±30 degrees, and ±40 degrees from the line of sight at near and distance. Photopic and mesopic pupil size were measured. The effects of peripheral defocus, treatment group, and pupil size on the 3-year change in axial length were modeled using multiple variables that evaluated defocus across the retina. Results: Although several peripheral defocus variables were associated with slower axial growth with MFCLs, they were either no longer significant or not meaningfully associated with eye growth after the treatment group was included in the model. The treatment group assignment better explained the slower eye growth with +2.50 MFCLs than peripheral defocus. Photopic and mesopic pupil size did not modify eye growth with the +2.50 MFCL (all P ≥ 0.37). Conclusions: The optical signal causing slower axial elongation with +2.50 MFCLs is better explained by the lens type worn than by peripheral defocus. The signal might be something other than peripheral defocus, or there is not a linear dose-response relationship within treatment groups. We found no evidence to support pupil size as a criterion when deciding which myopic children to treat with MFCLs.

Modeling and Evaluation of Ash-Forming Element Fate and Occurrence in Woody Biomass Combustion in an Entrained-Flow Burner.

Biomass combustion equipment is often susceptible to ash deposition due to the relatively significant quantities of potassium, silicon, and other ash-forming elements in biomass. To evaluate the propensity for ash deposition resulting from biomass combustion, a biomass combustion model was integrated with a chemical equilibrium model to predict the fate and occurrence of ash-forming elements in a pilot-scale entrained-flow burner. The integrated model simulated the combustion of white wood (virgin wood) and recycled wood (treated wood) previously combusted in the burner. The key advantage of this model in comparison to a model with general equilibrium assumed is that it was able to consider the rate of release of trace and minor species with time, the local equilibrium in the particles, and separately, that in the continuum phase (which also included any solid or liquid materials nucleating). The simulation generated the fate and occurrence profiles of each ash-forming element along the burner. The qualitative comparisons between the modeled profiles and the previous experimental findings under similar operating conditions show reasonable agreement. The concentrations of ash-forming elements released from the burner were also compared with the experimental online inductively coupled plasma readings. However, the latter comparison shows overestimation using the modeled results and might suggest that further considerations of other parameters such as ash nucleation and coagulation are required. Nonetheless, based on the ongoing performance of the integrated model, future use of the model might be expanded to a broader range of problematic solid fuels such as herbaceous biomass or municipal solid waste.

Digital Technologies for Children and Parents Sharing Self-Management in Childhood Chronic or Long-Term Conditions: A Scoping Review.

Worldwide, the prevalence of chronic (or long-term) conditions in children and young people from birth to 18 years (children) is increasing. Promoting competent and effective self-management skills early in the trajectory is important to improve adherence to treatment and optimise quality of life. Successful self-management, therefore, requires parents and children who are developmentally able to develop a range of complex skills, including the use of digital technologies. This scoping review aimed to identify primary research investigating digital technologies for children and parents sharing self-management in childhood chronic illnesses. A comprehensive search of electronic databases was conducted. Nineteen papers were included, assessed for quality and methodological rigour using the Hawker tool and thematically analysed. Three themes were identified: (i) the feasibility and acceptability of using technology, (ii) the usability of technologies and (iii) the effect of technologies on adherence and self-management skills. The results indicate that technologies such as mobile apps and websites can assist the management of long-term conditions, are an acceptable method of delivering information and can promote the development of effective self-management skills by parents and children. However, future technology design must include children and parents in all stages of development.

A randomized crossover trial assessing the effects of acute exercise on appetite, circulating ghrelin concentrations, and butyrylcholinesterase activity in normal-weight males with variants of the obesity-linked FTO rs9939609 polymorphism.

BACKGROUND: The fat mass and obesity-associated gene (FTO) rs9939609 A-allele is associated with higher acyl-ghrelin (AG) concentrations, higher energy intake, and obesity, although exercise may mitigate rs9939609 A-allele-linked obesity risk. Butyrylcholinesterase (BChE) hydrolyzes AG to des-acyl-ghrelin (DAG), potentially decreasing appetite. However, the effects of the FTO rs9939609 genotype and exercise on BChE activity, AG, DAG, and energy intake are unknown. OBJECTIVE: We hypothesized that individuals homozygous for the obesity-risk A-allele (AAs) would exhibit higher postprandial AG and energy intake than individuals homozygous for the low obesity-risk T-allele (TTs), but that exercise would increase BChE activity and diminish these differences. METHODS: Twelve AA and 12 TT normal-weight males completed a control (8 h rest) and an exercise (1 h of exercise at 70% peak oxygen uptake, 7 h rest) trial in a randomized crossover design. A fixed meal was consumed at 1.5 h and an ad libitum buffet meal at 6.5 h. Appetite, appetite-related hormones, BChE activity, and energy intake were assessed. RESULTS: AAs displayed lower baseline BChE activity, higher baseline AG:DAG ratio, attenuated AG suppression after a fixed meal, and higher ad libitum energy intake compared with TTs [effect sizes (ESs) ≥ 0.72, P ≤ 0.049]. Exercise increased Δ BChE activity in both genotypes (ESs = 0.37, P = 0.004); however, exercise lowered AG and the AG:DAG ratio to a greater extent in AAs (P ≤ 0.023), offsetting the higher AG profile observed in AAs during the control trial (ESs ≥ 1.25, P ≤ 0.048). Exercise did not elevate energy intake in either genotype (P = 0.282). CONCLUSIONS: Exercise increases BChE activity, suppresses AG and the AG:DAG ratio, and corrects the higher AG profile observed in obesity-risk AA individuals. These findings suggest that exercise or other methods targeting BChE activity may offer a preventative and/or therapeutic strategy for AA individuals. This trial was registered at clinicaltrials.gov as NCT03025347.

The Role of the Nurse Educator in Sustaining Compassion in the Workplace: A Case Study From an Intensive Care Unit.

Intensive care unit (ICU) nurses are frequently exposed to emotional and stressful situations in the workplace, which has changed little over the decades. Compassion fatigue is caused by sustained exposure to situations that conflict with one's values and beliefs in the ICU, eroding clinical team relationships and ultimately the quality and safety of patient care. Continuing education in the intensive care setting is a priority, as ICU nurses need to remain abreast of the rapid developments in high-acuity care delivery; however, attention also needs to be directed to nurses' emotional well-being. Nurse educators are well positioned to create and sustain open dialogue that contributes to group cohesion and assists nurses' well-being. J Contin Educ Nurs. 2018;49(5):221-224.

Entrained Metal Aerosol Emissions from Air-Fired Biomass and Coal Combustion for Carbon Capture Applications.

Biomass energy with CO2 capture could achieve net negative emissions, vital for meeting carbon budgets and emission targets. However, biomass often has significant quantities of light metals/inorganics that cause issues for boiler operation and downstream processes; including deposition, corrosion, and solvent degradation. This study investigated the pilot-scale combustion of a typical biomass used for power generation (white wood) and assessed the variations in metal aerosol release compared to bituminous coal. Using inductively coupled plasma optical emission spectrometry, it was found that K aerosol levels were significantly greater for biomass than coal, on average 6.5 times, with peaks up to 10 times higher; deposition could thus be more problematic, although Na emissions were only 20% of those for coal. Transition metals were notably less prevalent in the biomass flue gas; with Fe and V release in particular much lower (3⁻4% of those for coal). Solvent degradation may therefore be less severe for biomass-generated flue gases. Furthermore, aerosol emissions of toxic/heavy metals (As/Cd/Hg) were absent from biomass combustion, with As/Cd also not detected in the coal flue gas. Negligible Cr aerosol concentrations were found for both. Overall, except for K, metal aerosol release from biomass combustion was considerably reduced compared to coal.

Is Black Carbon an Unimportant Ice-Nucleating Particle in Mixed-Phase Clouds?

It has been hypothesized that black carbon (BC) influences mixed-phase clouds by acting as an ice-nucleating particle (INP). However, the literature data for ice nucleation by BC immersed in supercooled water are extremely varied, with some studies reporting that BC is very effective at nucleating ice, whereas others report no ice-nucleating ability. Here we present new experimental results for immersion mode ice nucleation by BC from two contrasting fuels (n-decane and eugenol). We observe no significant heterogeneous nucleation by either sample. Using a global aerosol model, we quantify the maximum relative importance of BC for ice nucleation when compared with K-feldspar and marine organic aerosol acting as INP. Based on the upper limit from our laboratory data, we show that BC contributes at least several orders of magnitude less INP than feldspar and marine organic aerosol. Representations of its atmospheric ice-nucleating ability based on older laboratory data produce unrealistic results when compared against ambient observations of INP. Since BC is a complex material, it cannot be unambiguously ruled out as an important INP species in all locations at all times. Therefore, we use our model to estimate a range of values for the density of active sites that BC particles must have to be relevant for ice nucleation in the atmosphere. The estimated values will guide future work on BC, defining the required sensitivity of future experimental studies.

Developing and maintaining compassionate care in nursing.

Compassionate care is a fundamental aspect of nursing, and is an important value that is embedded in nurses' professional standards and codes of practice. However, nurses may experience several challenges in their practice that can impede their ability to provide compassionate care. This article aims to support and guide nurses in developing their capacity to be compassionate. It explores concepts related to compassion, including compassion satisfaction, fatigue, literacy and self-compassion, and outlines strategies that nurses can implement to promote compassionate care. This article encourages nurses to identify their personal and professional values, to understand how these can influence their attitudes and behaviours. By raising awareness of these concepts, as well as the challenges and changing nature of compassion, it is hoped that nurses' capacity to provide compassionate care will be enhanced.

Chromatin immunoprecipitation analysis of gene expression in the rat uterus in vivo: estrogen-induced recruitment of both estrogen receptor alpha and hypoxia-inducible factor 1 to the vascular endothelial growth factor promoter.

Vascular endothelial growth factor (VEGF) plays a pivotal role in the regulation of microvascular permeability and angiogenesis, processes essential for normal endometrial growth and implantation. Estrogen [17beta-estradiol (E2)], via its receptor (ER alpha), rapidly stimulates VEGF expression in the uterus at the transcriptional level. The VEGF gene promoter, however, lacks a consensus estrogen response element (ERE), and attempts to identify the site through which E2 induces VEGF expression have yielded contradictory results. To address this question, we modified the chromatin immunoprecipitation method to identify transcription factors that interact with the VEGF promoter in the rat uterus in response to E2. Chromatin immunoprecipitation showed that both Sp1 and Sp3 were associated with a proximal, GC-rich region of the promoter before E2 treatment. E2 induced an increase in Sp1 binding and the recruitment of ER alpha, and the coactivator p300 to this region. The association of ER alpha persisted, however, after VEGF mRNA levels had declined again (at 4 h), indicating that other factors might be involved in that expression. Western analysis showed that both the alpha- and beta-subunits of the transcription factor hypoxia-inducible factor 1 (HIF-1), which regulates VEGF expression in response to hypoxia and several hormones and growth factors, were present in the uterus. Furthermore, E2 rapidly induced their recruitment to the -944 to -611 bp region of the VEGF promoter, which contains the hypoxia response element to which HIF-1 binds. This binding was transient, matching the pattern of E2-induced VEGF expression. These results indicate that HIF-1 is an important mediator of E2-induced VEGF expression in the uterus. In addition, E2 also induced a later increase in HIF-1alpha mRNA and protein expression in the uterus, suggesting that it may be required for longer term effects of E2 on the uterus as well. In contrast to the uterus, HEC1A cells cultured in 95% air-5% CO2 (and therefore 20% O2) contained no HIF-1alpha, consistent with the inability of E2 to stimulate the expression of VEGF by these and other cell types in vitro.

The acute (immediate) effects of reflexology on arterial compliance in healthy volunteers: A randomised study.

BACKGROUND: Reflexology is a widely used complementary therapy. The effects of reflexology on the cardiovascular system are not well characterised. Arterial stiffness (compliance) is a marker of vascular health. This study aimed to evaluate the effects of reflexology on arterial compliance in healthy volunteers. METHODS: 12 healthy volunteers (1 male; 11 female; mean age 44.8 ± 10.8 yrs) received 10 min of reflexology on each foot in a single-blind randomised study. The main outcome measures were measurements of cardiovascular parameters including heart rate, blood pressure and arterial compliance (augmentation index). RESULTS: Reflexology had no significant effect on heart rate, blood pressure or augmentation index (all p > 0.05). CONCLUSIONS: In healthy volunteers, there were no consistent changes in haemodynamic parameters with a single brief reflexology treatment. Thus from a cardiovascular point of view, reflexology (as delivered) would appear to have a limited (if any) effect on the cardiovascular system.

Appetite and Energy Intake Responses to Acute Energy Deficits in Females versus Males.

PURPOSE: To explore whether compensatory responses to acute energy deficits induced by exercise or diet differ by sex. METHODS: In experiment one, 12 healthy women completed three 9-h trials (control, exercise-induced (Ex-Def) and food restriction-induced energy deficit (Food-Def)) with identical energy deficits being imposed in the Ex-Def (90-min run, ∼70% of V˙O2max) and Food-Def trials. In experiment two, 10 men and 10 women completed two 7-h trials (control and exercise). Sixty minutes of running (∼70% of V˙O2max) was performed at the beginning of the exercise trial. The participants rested throughout the remainder of the exercise trial and during the control trial. Appetite ratings, plasma concentrations of gut hormones, and ad libitum energy intake were assessed during main trials. RESULTS: In experiment one, an energy deficit of approximately 3500 kJ induced via food restriction increased appetite and food intake. These changes corresponded with heightened concentrations of plasma acylated ghrelin and lower peptide YY3-36. None of these compensatory responses were apparent when an equivalent energy deficit was induced by exercise. In experiment two, appetite ratings and plasma acylated ghrelin concentrations were lower in exercise than in control, but energy intake did not differ between trials. The appetite, acylated ghrelin, and energy intake response to exercise did not differ between men and women. CONCLUSIONS: Women exhibit compensatory appetite, gut hormone, and food intake responses to acute energy restriction but not in response to an acute bout of exercise. Additionally, men and women seem to exhibit similar acylated ghrelin and PYY3-36 responses to exercise-induced energy deficits. These findings advance understanding regarding the interaction between exercise and energy homeostasis in women.

New insight into the transcriptional regulation of vascular endothelial growth factor expression in the endometrium by estrogen and relaxin.

Increased uterine capillary permeability, which can be induced by both estrogen and relaxin, is required for endometrial growth and implantation. This effect is mediated in both cases by estrogen receptors (ERs), via stimulation of vascular endothelial growth factor (VEGF) expression. The sites on the VEGF promoter through which induction occurs, however, are completely unclear. We have used the technique of chromatin immunoprecipitation in vivo to localize the site of ER action and identify other transcription factors that are involved. We have found that ERa associates with Sp1/Sp3 at a GC-rich region of the promoter. More interesting, however, is the observation that estrogen also induces rapid, transient binding of hypoxia-inducible factor 1 (HIF-1), which mediates VEGF transcription in response to hypoxia, to the promoter. The estrogen-induced HIF-1 binding closely matches the estrogen-induced pattern of VEGF expression in the uterus, suggesting that HIF-1 is involved in that induction, and probably that of many other genes as well (HIF-1 is now known to regulate the expression of more than 40 genes). It is likely that studies now under way will also link relaxin-induced VEGF expression to HIF-1. This is based on the similarities in the effects of the two hormones on VEGF expression and on their shared ability to activate the PI3K and MAPK pathways, both of which can activate HIF-1.

A case of severe anorexia, excessive weight loss and high peptide YY levels after sleeve gastrectomy.

UNLABELLED: Sleeve gastrectomy (SG) is the second most commonly performed bariatric procedure worldwide. Altered circulating gut hormones have been suggested to contribute post-operatively to appetite suppression, decreased caloric intake and weight reduction. In the present study, we report a 22-year-old woman who underwent laparoscopic SG for obesity (BMI 46 kg/m(2)). Post-operatively, she reported marked appetite reduction, which resulted in excessive weight loss (1-year post-SG: BMI 22 kg/m(2), weight loss 52%, >99th centile of 1-year percentage of weight loss from 453 SG patients). Gastrointestinal (GI) imaging, GI physiology/motility studies and endoscopy revealed no anatomical cause for her symptoms, and psychological assessments excluded an eating disorder. Despite nutritional supplements and anti-emetics, her weight loss continued (BMI 19 kg/m(2)), and she required nasogastric feeding. A random gut hormone assessment revealed high plasma peptide YY (PYY) levels. She underwent a 3 h meal study following an overnight fast to assess her subjective appetite and circulating gut hormone levels. Her fasted nausea scores were high, with low hunger, and these worsened with nutrient ingestion. Compared to ten other post-SG female patients, her fasted circulating PYY and nutrient-stimulated PYY and active glucagon-like peptide 1 (GLP1) levels were markedly elevated. Octreotide treatment was associated with suppressed circulating PYY and GLP1 levels, increased appetite, increased caloric intake and weight gain (BMI 22 kg/m(2) after 6 months). The present case highlights the value of measuring gut hormones in patients following bariatric surgery who present with anorexia and excessive weight loss and suggests that octreotide treatment can produce symptomatic relief and weight regain in this setting. LEARNING POINTS: Roux-en-Y gastric bypass and SG produce marked sustained weight reduction. However, there is a marked individual variability in this reduction, and post-operative weight loss follows a normal distribution with extremes of 'good' and 'poor' response.Profound anorexia and excessive weight loss post-SG may be associated with markedly elevated circulating fasted PYY and post-meal PYY and GLP1 levels.Octreotide treatment can produce symptomatic relief and weight regain for post-SG patients that have an extreme anorectic and weight loss response.The present case highlights the value of measuring circulating gut hormone levels in patients with post-operative anorexia and extreme weight loss.