Stratospheric air intrusions promote global-scale new particle formation.

New particle formation in the free troposphere is a major source of cloud condensation nuclei globally. The prevailing view is that in the free troposphere, new particles are formed predominantly in convective cloud outflows. We present another mechanism using global observations. We find that during stratospheric air intrusion events, the mixing of descending ozone-rich stratospheric air with more moist free tropospheric background results in elevated hydroxyl radical (OH) concentrations. Such mixing is most prevalent near the tropopause where the sulfur dioxide (SO2) mixing ratios are high. The combination of elevated SO2 and OH levels leads to enhanced sulfuric acid concentrations, promoting particle formation. Such new particle formation occurs frequently and over large geographic regions, representing an important particle source in the midlatitude free troposphere.

First Bite Syndrome Relief With Trigeminal Nerve Branch Block and Ablation: A Case Report.

First bite syndrome (FBS) is intense facial pain at the first bite of each meal. Currently, no guidelines exist for treating FBS, although botulinum toxin injection has shown benefit. We describe a case of right-sided FBS and painful trigeminal neuropathy, in which FBS resolved for 2 weeks using maxillary and mandibular nerve block and radiofrequency nerve thermal ablation (RFA). Our treatment may have disrupted somatic sensory input from the parotid carried by the auriculotemporal nerve or lesioned the otic ganglion resulting in decreased parasympathetic hyperactivation. Further studies are warranted to evaluate the use of this procedure for FBS.

Global Measurements of Brown Carbon and Estimated Direct Radiative Effects.

Brown carbon (BrC) is an organic aerosol material that preferentially absorbs light of shorter wavelengths. Global-scale radiative impacts of BrC have been difficult to assess due to the lack of BrC observational data. To address this, aerosol filters were continuously collected with near pole-to-pole latitudinal coverage over the Pacific and Atlantic basins in three seasons as part of the Atmospheric Tomography Mission. BrC chromophores in filter extracts were measured. We find that globally, BrC was highly spatially heterogeneous, mostly detected in air masses that had been transported from regions of extensive biomass burning. We calculate the average direct radiative effect due to BrC absorption accounted for approximately 7% to 48% of the top of the atmosphere clear-sky instantaneous forcing by all absorbing carbonaceous aerosols in the remote atmosphere, indicating that BrC from biomass burning is an important component of the global radiative balance.

Global airborne sampling reveals a previously unobserved dimethyl sulfide oxidation mechanism in the marine atmosphere.

Dimethyl sulfide (DMS), emitted from the oceans, is the most abundant biological source of sulfur to the marine atmosphere. Atmospheric DMS is oxidized to condensable products that form secondary aerosols that affect Earth's radiative balance by scattering solar radiation and serving as cloud condensation nuclei. We report the atmospheric discovery of a previously unquantified DMS oxidation product, hydroperoxymethyl thioformate (HPMTF, HOOCH2SCHO), identified through global-scale airborne observations that demonstrate it to be a major reservoir of marine sulfur. Observationally constrained model results show that more than 30% of oceanic DMS emitted to the atmosphere forms HPMTF. Coincident particle measurements suggest a strong link between HPMTF concentration and new particle formation and growth. Analyses of these observations show that HPMTF chemistry must be included in atmospheric models to improve representation of key linkages between the biogeochemistry of the ocean, marine aerosol formation and growth, and their combined effects on climate.

A large source of cloud condensation nuclei from new particle formation in the tropics.

Cloud condensation nuclei (CCN) can affect cloud properties and therefore Earth's radiative balance1-3. New particle formation (NPF) from condensable vapours in the free troposphere has been suggested to contribute to CCN, especially in remote, pristine atmospheric regions4, but direct evidence is sparse, and the magnitude of this contribution is uncertain5-7. Here we use in situ aircraft measurements of vertical profiles of aerosol size distributions to present a global-scale survey of NPF occurrence. We observe intense NPF at high altitudes in tropical convective regions over both Pacific and Atlantic oceans. Together with the results of chemical-transport models, our findings indicate that NPF persists at all longitudes as a global-scale band in the tropical upper troposphere, covering about 40 per cent of Earth's surface. Furthermore, we find that this NPF in the tropical upper troposphere is a globally important source of CCN in the lower troposphere, where CCN can affect cloud properties. Our findings suggest that the production of CCN as new particles descend towards the surface is not adequately captured in global models, which tend to underestimate both the magnitude of tropical upper tropospheric NPF and the subsequent growth of new particles to CCN sizes.

Efficient In-Cloud Removal of Aerosols by Deep Convection.

Convective systems dominate the vertical transport of aerosols and trace gases. The most recent in situ aerosol measurements presented here show that the concentrations of primary aerosols including sea salt and black carbon drop by factors of 10 to 10,000 from the surface to the upper troposphere. In this study we show that the default convective transport scheme in the National Science Foundation/Department of Energy Community Earth System Model results in a high bias of 10-1,000 times the measured aerosol mass for black carbon and sea salt in the middle and upper troposphere. A modified transport scheme, which considers aerosol activation from entrained air above the cloud base and aerosol-cloud interaction associated with convection, dramatically improves model agreement with in situ measurements suggesting that deep convection can efficiently remove primary aerosols. We suggest that models that fail to consider secondary activation may overestimate black carbon's radiative forcing by a factor of 2.

SAM-CAAM: A Concept for Acquiring Systematic Aircraft Measurements to Characterize Aerosol Air Masses.

A modest operational program of systematic aircraft measurements can resolve key satellite-aerosol-data-record limitations. Satellite observations provide frequent, global aerosol-amount maps, but offer only loose aerosol property constraints needed for climate and air quality applications. We define and illustrate the feasibility of flying an aircraft payload to measure key aerosol optical, microphysical, and chemical properties in situ. The flight program could characterize major aerosol air-mass types statistically, at a level-of-detail unobtainable from space. It would: (1) enhance satellite aerosol retrieval products with better climatology assumptions, and (2) improve translation between satellite-retrieved optical properties and species-specific aerosol mass and size simulated in climate models to assess aerosol forcing, its anthropogenic components, and other environmental impacts. As such, Systematic Aircraft Measurements to Characterize Aerosol Air Masses (SAM-CAAM) could add value to data records representing several decades of aerosol observations from space, improve aerosol constraints on climate modeling, help interrelate remote-sensing, in situ, and modeling aerosol-type definitions, and contribute to future satellite aerosol missions. Fifteen Required Variables are identified, and four Payload Options of increasing ambition are defined, to constrain these quantities. "Option C" could meet all the SAM-CAAM objectives with about 20 instruments, most of which have flown before, but never routinely several times per week, and never as a group. Aircraft integration, and approaches to data handling, payload support, and logistical considerations for a long-term, operational mission are discussed. SAM-CAAM is feasible because, for most aerosol sources and specified seasons, particle properties tend to be repeatable, even if aerosol loading varies.

Advances in functional neuroimaging in dementias and potential pitfalls.

Neuroimaging is continuously advancing at a rapid rate and has progressed from excluding relatively uncommon secondary causes (stroke, tumor) to assisting with early diagnosis and subtype of dementia. Structural imaging has given way to functional, metabolic and receptor imaging.

CCN spectra, hygroscopicity, and droplet activation kinetics of secondary organic aerosol resulting from the 2010 Deepwater Horizon oil spill.

Secondary organic aerosol (SOA) resulting from the oxidation of organic species emitted by the Deepwater Horizon oil spill were sampled during two survey flights conducted by a National Oceanic and Atmospheric Administration WP-3D aircraft in June 2010. A new technique for fast measurements of cloud condensation nuclei (CCN) supersaturation spectra called Scanning Flow CCN Analysis was deployed for the first time on an airborne platform. Retrieved CCN spectra show that most particles act as CCN above (0.3 ± 0.05)% supersaturation, which increased to (0.4 ± 0.1)% supersaturation for the most organic-rich aerosol sampled. The aerosol hygroscopicity parameter, κ, was inferred from both measurements of CCN activity and from humidified-particle light extinction, and varied from 0.05 to 0.10 within the emissions plumes. However, κ values were lower than expected from chemical composition measurements, indicating a degree of external mixing or size-dependent chemistry, which was reconciled assuming bimodal, size-dependent composition. The CCN droplet effective water uptake coefficient, γ(cond), was inferred from the data using a comprehensive instrument model, and no significant delay in droplet activation kinetics from the presence of organics was observed, despite a large fraction of hydrocarbon-like SOA present in the aerosol.

Impact of fuel quality regulation and speed reductions on shipping emissions: implications for climate and air quality.

Atmospheric emissions of gas and particulate matter from a large ocean-going container vessel were sampled as it slowed and switched from high-sulfur to low-sulfur fuel as it transited into regulated coastal waters of California. Reduction in emission factors (EFs) of sulfur dioxide (SO2), particulate matter, particulate sulfate and cloud condensation nuclei were substantial (≥ 90%). EFs for particulate organic matter decreased by 70%. Black carbon (BC) EFs were reduced by 41%. When the measured emission reductions, brought about by compliance with the California fuel quality regulation and participation in the vessel speed reduction (VSR) program, are placed in a broader context, warming from reductions in the indirect effect of SO4 would dominate any radiative changes due to the emissions changes. Within regulated waters absolute emission reductions exceed 88% for almost all measured gas and particle phase species. The analysis presented provides direct estimations of the emissions reductions that can be realized by California fuel quality regulation and VSR program, in addition to providing new information relevant to potential health and climate impact of reduced fuel sulfur content, fuel quality and vessel speed reductions.

The First National Pain Medicine Summit--final summary report.

Pain is ubiquitous. At some point in time it affects everyone. For many millions pain becomes chronic, a scourge that impacts every facet of life-work, hobbies, family relations, social fabric, finances, happiness, mood, and even the very essence of identity. According to the National Institutes of Health (NIH), pain is one of our most important national public health problems, a silent epidemic. In 1998, NIH reported that the annual amount spent on health care, compensation, and litigation related to pain had reached one hundred billion dollars ($100,000,000,000). Considering that health care costs have doubled since then, it is not unreasonable to assume that the costs related to pain care have doubled as well. Millions of patients suffer needlessly with acute pain, with cancer pain, and with chronic pain. The ineffective management of pain results in an escalating cascade of health care issues. Acute pain that is not treated adequately and promptly results in persistent pain that eventually causes irreversible changes in the nervous system. This translates into progressive bio-psycho-social epiphenomena resulting in further pain and disability. It creates a vicious cycle transforming a functional human being into an invalid who becomes a burden to family, to society, and to oneself. In the face of adequate medical science, adequate technical skills, and adequate resources the reality of delayed and inadequate pain care is paradoxical. This dilemma deserves close scrutiny and effective remediation. The American Medical Association (AMA), long dedicated to the need to improve pain care in this country, has been faced with this reality. It was from this vision that the idea of holding a Pain Medicine Summit was conceived. Resolution 321 (A-08) set in motion a process that would bring together a diverse group of stakeholders for the purpose of discussing the present and future status of pain care; a process that culminated in a broad-based coalition of physicians and organizations dedicated to improving pain care, the first National Pain Medicine Summit. The process began with the adoption of Resolution 321 (A-08) at an AMA Annual House of Delegates meeting in June 2008. Resolution 321 (A-08) states, in part, that "...the AMA encourages relevant specialties to collaborate in studying: 1) the scope and practice and body of knowledge encompassed by the field of Pain Medicine; 2) the adequacy of undergraduate, graduate, and post graduate education in the principles and practices of the field of Pain Medicine, considering the current and anticipated medical need for the delivery of quality pain care; and 3) appropriate training and credentialing criteria for this multi-disciplinary field of medical practice." The next step was delegating the responsibility for implementing Resolution 321 (A-08) to the Pain and Palliative Medicine Specialty Section Council (PPMSSC). The PPMSSC, under the direction of its chairman, Philipp M. Lippe, MD, FACS, assumed responsibility in November 2008 for identifying a process that would achieve the goals established by Resolution 321 (A-08). The PPMSSC in turn established an Advisory Committee, charged with strategic planning, and an Implementation Committee, charged with tactical operations. The two groups began work immediately. The process included three distinct phases centered on a Pain Medicine Summit. Phase One involved a modified Delphi process identifying the five most pressing and relevant themes in pain care. Phase Two consisted of the Pain Medicine Summit itself, including a gathering of representatives from across the pain care spectrum to address the previously identified five most pressing themes. Phase Three was the preparation of this report, which describes the conclusions drawn and recommendations developed by the attendees at the Pain Medicine Summit. Based on a recommendation from the Advisory Committee, the PPMSSC decided to retain the services of a consulting firm to help the PPMSSC implement the Pain Medicine Summit process. In August 2009, PPMSSC selected Grey Matters, a New York-based advisory firm. The PPMSSC also appointed a Steering Committee to assist Grey Matters and to coordinate all activities. The Committee consisted of Charles Brock, MD; Ronald Crossno, MD; Jose David, MD; Michel Dubois, MD; Albert Ray, MD; and Philipp M. Lippe, MD, FACS (chair). The consulting firm, Grey Matters, proposed a multi-phasic process in order to facilitate the implementation of the Pain Medicine Summit and to ensure a coordinated, efficient, and productive outcome. This process consisting of three phases-pre-summit, summit, and post-summit-is described in detail in the following section. All aspects of the project were closely coordinated and supervised by the Steering Committee, which included the selection of the team leaders of the five Workgroups, based on specific criteria. The Pain Medicine Summit, adhering to the dictates of Resolution 321 (A-08), explored the body of knowledge and the scope of practice of Pain Medicine; the education and training in medical school, graduate, and postgraduate programs; and the credentialing and certification processes in the field of Pain Medicine. It addressed the barriers hampering delivery of high quality pain care. It recognized the need for clarification and consensus in many areas. Several points of consensus emerged: The continuum of medical education in the field of Pain Medicine is inadequate and fragmented. It needs to be fortified in scope, content, and duration. Credentialing and certification processes in Pain Medicine are variable, diverse, and deficient in many instances. Deficiencies in these areas lead to suboptimal and fragmented pain care having a negative impact on direct patient care and public health. Effective and prompt remediation is desirable and essential to achieving the goal of high quality pain care. Barriers exist inhibiting or retarding progress toward the common good. There are several viable avenues to achieving our stated goal, "excellence in the delivery of high quality, cost-effective pain care to the patients we serve," including the development of Pain Medicine as a distinct specialty with ACGME accredited residency programs and ABMS certification. The Pain Medicine Summit concluded with a number of recommendations, including the following: That the pain community remains engaged in addressing the issues raised and in mitigating the barriers. That the recommendations be referred to the AMA and the PPMSSC for support and implementation. That another national Pain Medicine Summit with enhanced participation be convened. That consideration be given to convening an International Pain Summit in conjunction with the IASP World Congress in Montreal. That the final report of the Pain Medicine Summit be widely disseminated.

Sex differences in the adequacy of pain management among patients referred to a multidisciplinary cancer pain clinic.

Few studies have evaluated sex differences in the adequacy of pain management in cancer. Existing studies have been marked by methodological limitations and results have been mixed. The present study sought to determine whether sex was associated with pain severity and pain management in cancer patients newly referred by their primary oncology team to a multidisciplinary cancer pain clinic. One hundred thirty-one cancer patients completed the Brief Pain Inventory-Short Form and medical chart review was conducted to obtain patients' clinical characteristics and pain treatment data. There were no differences between males and females in ratings of worst pain in the last week. Females were significantly less likely to have been prescribed high potency opioids by their primary oncology team and significantly more likely to report inadequate pain management as measured by Pain Management Index scores. These results suggest a sex bias in the treatment of cancer pain and support the routine examination of the effect of sex in cancer pain research.

Neurologic improvement after high-dose intravenous immunoglobulin therapy in patients with paraneoplastic cerebellar degeneration associated with anti-Purkinje cell antibody.

Paraneoplastic cerebellar degeneration (PCD) is a rare syndrome associated with systemic malignancies, most in lung and ovarian cancer. Cerebellar ataxia has previously been associated with the presence of anti-Purkinje cell antibodies (anti-Yo) in the serum and cerebrospinal fluid and responses to therapy are uncommon. We reported two patients were identified with delayed onset of PCD associated with high titer of CSF anti-Yo (1:30,000, 1:320 U/ml) and a marked elevation of tumor markers for ovarian cancer (CA-125 17,700 ng/ml, 43 ng/ml) titer 1 year and 6 months prior to discovery of the carcinoma. Both developed subacute onset of severe ataxia, dysarthria, tremor, nystagmus with progression to severe debilitation (wheelchair bound or bedridden status). One of these patients also developed dysphagia that required PEG tube feeding. They were treated with six cycles of intravenous immunoglobulin (IVIG) 0.4 gm/kg/day x 5 days, every 4-6 weeks in conjunction with combination chemotherapy of Taxol and Carboplatin after the surgical resection of ovarian cancer. In each case, a significant improvement of neurological deficits were seen after the third cycle of IVIG, approximately 4 months after initiation of treatment. This type of delayed response is contrary to the previous reports. Both patients could ambulate without assistance in correlation with dramatic decrease in anti-Yo titer (1:80, 1:320 U/ml) and CA-125 (11 ng/ml, 8 ng/ml). This is a first report of benefit from IVIG in patients with late onset of PCD, which showed a delayed response with significant neurological improvement.