Microwave observations reveal the deep extent and structure of Jupiter's atmospheric vortices.

Jupiter's atmosphere has a system of zones and belts punctuated by small and large vortices, the largest being the Great Red Spot. How these features change with depth is unknown, with theories of their structure ranging from shallow meteorological features to surface expressions of deep-seated convection. We present observations of atmospheric vortices using the Juno spacecraft's Microwave Radiometer. We found vortex roots that extend deeper than the altitude at which water is expected to condense, and we identified density inversion layers. Our results constrain the three-dimensional structure of Jupiter's vortices and their extension below the clouds.

Associations of marijuana with markers of chronic lung disease in people living with HIV.

OBJECTIVES: The relationship between marijuana use and markers of chronic lung disease in people living with HIV (PLWH) is poorly understood. METHODS: We performed a cross-sectional analysis of the Examinations of HIV-Associated Lung Emphysema (EXHALE) study, including 162 HIV-positive patients and 138 participants without HIV. We modelled marijuana exposure as: (i) current daily or weekly marijuana smoking vs. monthly or less often; or (ii) cumulative marijuana smoking (joint-years). Linear and logistic regression estimated associations between marijuana exposure and markers of lung disease, adjusted for tobacco smoking and other factors. RESULTS: In PLWH, current daily or weekly marijuana use was associated with a larger forced vital capacity (FVC), larger total lung capacity and increased odds of radiographic emphysema compared with marijuana non-smokers in adjusted models; these associations were not statistically significant in participants without HIV. Marijuana joint-years were associated with higher forced expiratory volume in 1 s and FVC in PLWH but not with emphysema. CONCLUSIONS: In PLWH, marijuana smoking was associated with higher lung volumes and potentially with radiographic emphysema. No consistently negative associations were observed between marijuana and measures of chronic lung health.

Impact of defined clinical population and missing data on temporal trends in HIV viral load estimation within a health care system.

OBJECTIVES: Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Health Administration (VA) to determine trends in the health care system viral load (HSVL) and its sensitivity to varying definitions of the clinical population and assumptions regarding missing data. METHODS: We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with at least one documented CD4 count, HIV-1 RNA or antiretroviral prescription (n = 37 318). We created 6-month intervals including patients with at least one visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load. RESULTS: The clinical population size varied by definition, increasing from 16 000-19 000 patients in 2000 to 23 000-26 000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or the past 2 years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97 800 HIV-1 RNA copies/mL in 2000 to 2000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322 300 to 9900 copies/mL. HSVL was underestimated when using only current data in each interval. CONCLUSIONS: The CVL concept can be applied to a health care system, providing a measure of health care quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.

Cost-effectiveness analysis of neoadjuvant pertuzumab and trastuzumab therapy for locally advanced, inflammatory, or early HER2-positive breast cancer in Canada.

OBJECTIVE: The NeoSphere trial demonstrated that the addition of pertuzumab to trastuzumab and docetaxel for the neoadjuvant treatment of HER2-positive locally advanced, inflammatory, or early breast cancer (eBC) resulted in a significant improvement in pathological complete response (pCR). Furthermore, the TRYPHAENA trial supported the benefit of neoadjuvant dual anti-HER2 therapy. Survival data from these trials is not yet available; however, other studies have demonstrated a correlation between pCR and improved event-free survival (EFS) and overall survival (OS) in this patient population. This study represents the first Canadian cost-effectiveness analysis of pertuzumab in the neoadjuvant treatment of HER2-positive eBC. METHODS: A cost-utility analysis (CUA) was conducted using a three health state Markov model ('event-free', 'relapsed', and 'dead'). Two separate analyses were conducted; the first considering total pCR (ypT0/is ypN0) data from NeoSphere, and the second from TRYPHAENA. Published EFS and OS data partitioned for patients achieving/not achieving pCR were used in combination with the percentage achieving pCR in the pertuzumab trials to estimate survival. This CUA included published utility values and direct medical costs including drugs, treatment administration, management of adverse events, supportive care, and subsequent therapy. To address uncertainty, a probabilistic sensitivity analysis (PSA) and alternative scenarios were explored. RESULTS: Both analyses suggested that the addition of pertuzumab resulted in increased life-years and quality-adjusted life-years (QALYs). The incremental cost per QALY ranged from $25,388 (CAD; NeoSphere analysis) to $46,196 (TRYPHAENA analysis). Sensitivity analyses further support the use of pertuzumab, with cost-effectiveness ratios ranging from $9230-$64,421. At a threshold of $100,000, the addition of pertuzumab was cost-effective in nearly all scenarios (93% NeoSphere; 79% TRYPHAENA). CONCLUSION: Given the improvement in clinical efficacy and a favorable cost per QALY, the addition of pertuzumab in the neoadjuvant setting represents an attractive treatment option for HER2-positive eBC patients.

Towards a combined prognostic index for survival in HIV infection: the role of 'non-HIV' biomarkers.

BACKGROUND: As those with HIV infection live longer, 'non-AIDS' condition associated with immunodeficiency and chronic inflammation are more common. We ask whether 'non-HIV' biomarkers improve differentiation of mortality risk among individuals initiating combination antiretroviral therapy (cART). METHODS: Using Poisson models, we analysed data from the Veterans Aging Cohort Study (VACS) on HIV-infected veterans initiating cART between 1 January 1997 and 1 August 2002. Measurements included: HIV biomarkers (CD4 cell count, HIV RNA and AIDS-defining conditions); 'non-HIV' biomarkers (haemoglobin, transaminases, platelets, creatinine, and hepatitis B and C serology); substance abuse or dependence (alcohol or drug); and age. Outcome was all cause mortality. We tested the discrimination (C statistics) of each biomarker group alone and in combination in development and validation data sets, over a range of survival intervals, and adjusting for missing data. RESULTS: Of veterans initiating cART, 9784 (72%) had complete data. Of these, 2566 died. Subjects were middle-aged (median age 45 years), mainly male (98%) and predominantly black (51%). HIV and 'non-HIV' markers were associated with each other (P < 0.0001) and discriminated mortality (C statistics 0.68-0.73); when combined, discrimination improved (P < 0.0001). Discrimination for the VACS Index was greater for shorter survival intervals [30-day C statistic 0.86, 95% confidence interval (CI) 0.80-0.91], but good for intervals of up to 8 years (C statistic 0.73, 95% CI 0.72-0.74). Results were robust to adjustment for missing data. CONCLUSIONS: When added to HIV biomarkers, 'non-HIV' biomarkers improve differentiation of mortality. When evaluated over similar intervals, the VACS Index discriminates as well as other established indices. After further validation, the VACS Index may provide a useful, integrated risk assessment for management and research.

Functional mitochondria are required for O2 but not CO2 sensing in immortalized adrenomedullary chromaffin cells.

Catecholamine (CAT) release from adrenomedullary chromaffin cells (AMC) in response to stressors such as low O(2) (hypoxia) and elevated CO(2)/H(+) is critical during adaptation of the newborn to extrauterine life. Using a surrogate model based on a v-myc immortalized adrenal chromaffin cell line (i.e., MAH cells), combined with genetic perturbation of mitochondrial function, we tested the hypothesis that functional mitochondria are required for O(2) sensing. Wild-type MAH cells responded to both hypoxia and increased CO(2) (hypercapnia) with K(+) current inhibition and membrane depolarization. Additionally, these stimuli caused a rise in cytosolic Ca(2+) and CAT secretion, determined by fura-2 spectrofluorimetry and carbon fiber amperometry, respectively. In contrast, mitochondria-deficient (rho(0)) MAH cells were hypoxia insensitive, although responses to hypercapnia and expression of several markers, including carbonic anhydrase II, remained intact. Rotenone (1 microM), a mitochondrial complex I blocker known to mimic and occlude the effects of hypoxia in primary AMC, was effective in wild-type but not rho(0) MAH cells. These data demonstrate that functional mitochondria are involved in hypoxia-sensing by adrenal chromaffin cells. We also show for the first time that, like their neonatal chromaffin cell counterparts, MAH cells are CO(2) sensors; however, this property is independent of functional mitochondria.

O2 sensing by recombinant TWIK-related halothane-inhibitable K+ channel-1 background K+ channels heterologously expressed in human embryonic kidney cells.

Hypoxic inhibition of K+ channels provides a link between low O2 and cell function, and in glossopharyngeal neurons hypoxic inhibition of a TWIK-related halothane-inhibitable K+ channel-1 (THIK-1)-like background K+ channel regulates neuronal function. In the present study, we examined directly the O2 sensitivity of recombinant THIK-1 channels, expressed in human embryonic kidney (HE293) cells. THIK-1 expression conferred a moderately outwardly rectifying halothane-inhibited and arachidonic acid-potentiated K+ current and invoked a strongly hyperpolarized resting membrane potential. Endogenous K+ currents in untransfected cells were unaffected by either agent. Hypoxia (P(O2), 20 mmHg) reversibly inhibited THIK-1 currents and caused membrane depolarization, effects that were occluded by halothane. Neither the mitochondrial complex I inhibitors rotenone, myxothiazol and sodium cyanide, nor the NADPH oxidase inhibitors diphenylene iodonium and phenylarsine oxide, were effective in inhibiting the O2-sensitivity of THIK-1. Thus, hypoxic inhibition of THIK-1 occurs by a mechanism dissimilar to that which regulates the activity of other members of the background K+ channel family. Given the O2 sensitivity of THIK-1 channels and their abundant expression in the CNS, we raise for the first time the possibility of a physiological and/or pathological role for these channels during brain ischemia.

Women's Evaluation of Intrapartum Nonpharmacological Pain Relief Methods Used during Labor.

A wide variety of pain relief measures are available to women in labor. This retrospective, descriptive survey design study examined which nonpharmacologic pain-relief techniques laboring women use most often and the effectiveness of the chosen techniques. Of the 10 nonpharmacological strategies rated by the sample (N = 46), breathing techniques, relaxation, acupressure, and massage were found to be the most effective. However, no specific technique or techniques were helpful for all participants. The results provide directions for childbirth educators in designing and implementing an effective childbirth education curriculum that assists women to have empowered birth experiences.

Outcomes analysis of a pain management project for two rural hospitals.

There has been a strong emphasis on effective pain management in recent years, yet application of new knowledge and research in the area seems to be implemented inadequately. Traditional educational approaches for clinicians must be complemented by interventions in health care systems that more directly influence the routine behaviors of clinicians. In an effort to address this problem, a project was designed to increase institutional commitment to improving pain management in two rural hospitals. The purpose of this article is to present the change process used and the findings from the program.

The volunteer anesthetist: a personal view.

The most common opportunities for nurse anesthetists to be involved in volunteer anesthesia overseas are usually on a surgical team to provide direct care for selected types of patients or to be involved in teaching local anesthesia providers. The challenges are numerous and unique in each setting. Sharing of knowledge, directly as an instructor or indirectly as a provider, provides for a great impact on health care delivery in many emerging nations. The anesthesia provider who is working to deliver care in another country must consider many variables before taking on such a venture. The type of surgical team or teaching assignment one accepts will determine the type of preparation that must be done before departing. In addition to the many organizational items, one should consider some personal issues as well. Lost wages, transportation costs, and lodging expenses are often paid for by the volunteer. Time away from one's family may also be a consideration. Health care, such as updated immunizations, must be attended to before to departure. Volunteers must be able to provide good care in less than ideal situations, and often with much less equipment and medications than are available in the United States. A review of some of the issues that one should consider before deciding to be a volunteer are outlined in this article. The nurse anesthetist who successfully anticipates and deals with the challenges of volunteer anesthesia will be rewarded with an intense degree of personal satisfaction. The ability to give back to the profession and those who would otherwise not have access to one's skills or knowledge produces a sense of accomplishment that is unique.

Indinavir-associated maculopapular eruption.

Indinavir-associated adverse dermatologic reactions are rare but do occur. A 39-year-old man who was positive for the human immunodeficiency virus and had no known allergy, developed an erythematous, maculopapular eruption several hours after switching to a new triple-drug regimen consisting of stavudine, didanosine, and indinavir. The eruption completely resolved 2 weeks after he discontinued the antiretroviral combination. To preserve future treatment options, the patient was sequentially rechallenged with each agent and confirmed indinavir as the cause. The patient tolerated and responded to a new combination of stavudine, didanosine, and nelfinavir. The rapid onset of the adverse reaction suggested that it might have been immunoglobulin-E mediated. No cross-sensitivity between indinavir and nelfinavir was apparent.

Conflict management: assessing educational needs.

In today's healthcare environment, the potential for conflict among healthcare providers exists as changes are occurring at a supersonic pace. The outcomes of conflict may affect patient care and are directly related to the effectiveness of the resolution. Clinical educators and staff development educators are essential in resolution if they assess strategies that are currently being used in managing conflict and then offer more effective resolution strategies.

Assessment of nurses' attitudes and knowledge regarding pain management.

BACKGROUND: RNs in North Carolina were surveyed to determine their current knowledge and to determine if educational preparation, practice setting, or clinical specialty influenced their knowledge levels and attitudes. METHOD: A stratified random sample of 1,000 practicing RNs in North Carolina were surveyed using the Nurses' Knowledge and Attitudes Survey Instrument developed by McCaffery and Ferrell. RESULTS: The mean score was 64.58 based on the percentage of correct responses from the 260 subjects who participated. No statistically significant difference was found in scores based on educational preparation, practice setting, or clinical specialty. CONCLUSION: The findings of this study support the concern of inadequate knowledge and inappropriate attitudes regarding pain management. It reveals the need for intensive continuing education and staff development.

Factors that influence patient satisfaction in the emergency department.

This descriptive correlation study examined the satisfaction levels of urgent and nonurgent patients in relation to nursing care, the emergency department (ED) environment, ancillary services, and information received. The sample consisted of 28 subjects, with the majority of patients being very satisfied with nursing care. The primary area of concern was information about the length of waiting time. The satisfaction levels of ED patients with the care they receive has become increasingly important in today's health care environment. ED nurses play an important role in ensuring that patients are satisfied and receive quality care.

Humor and pain management. A review of current literature.

The purpose of this article is to provide a review of current literature related to humor and pain management. A brief review of the benefits of humor on the body is followed by a literature review of articles on humor and pain management, including research articles and scholarly articles on the topic. Research studies on the use of humor with both acute and chronic pain will be reported. The review of scholarly unresearched articles will include articles giving guidelines for humor use, suggested humor assessment guidelines, discussion of the nurse's role with humor use, and implementation strategies via humor carts and rooms.

Regulation of the RAG-1 promoter by the NF-Y transcription factor.

We have cloned the RAG-1 promoter region and have determined that almost all detectable promoter activity resides within a 208-bp fragment. Sequence analysis of this promoter region has identified potential recognition motifs for a number of lymphocyte-restricted and ubiquitous transcription factors. Subsequent assays have revealed that the NF-Y transcription factor interacts with a CCAAT site within the RAG-1 promoter and appears to play an important role in the positive transcriptional regulation of this gene.

Perceived competence and actual level of knowledge of diabetes mellitus among nurses.

Staff nurses were surveyed on their perceived and actual level of knowledge of diabetes mellitus. Staff nurses (n = 32) employed at a rural 62-bed acute care hospital in the southeastern United States constituted a convenience sample. The Diabetes Self-Report Tool was used to assess staff nurses' perceptions of knowledge of diabetes mellitus. Using a Likert-type scale a mean score of 88% was obtained concerning perceived knowledge. The Diabetes Basic Knowledge Test was used to measure the actual level of knowledge of diabetes mellitus. A mean score of 75% was obtained on the Diabetes Basic Knowledge Test. Nurses' perception of knowledge was not related to actual knowledge scores. Study findings raise questions for the nurse involved in staff development concerning the adequacy of nursing competency validation in the area of diabetes management.

A self-management program for chronic obstructive pulmonary disease: relationship to dyspnea and self-efficacy.

The purpose of this quasi-experimental study was to determine the effects of a nurse-directed self-management program on dyspnea and self-efficacy levels in patients with chronic obstructive pulmonary disease (COPD). The Health Belief Model and the Theory of Self-Efficacy provided the theoretical framework for the study. The sample included 10 COPD patients from rural North Carolina who attended a 6-week nurse-directed self-management program. Dyspnea and self-efficacy were measured before and after the program by using a vertical visual analogue scale for dyspnea and the COPD Self-Efficacy Scale. A single-group quasi-experimental design that incorporated a pretest and a posttest was used. Paired t tests were used to compare the pretest and the posttest levels of dyspnea and self-efficacy. The findings revealed no significant change in levels of dyspnea after the program. Levels of self-efficacy, however, were found to have increased at a statistically significant level (p < .001) following the program. This study indicates that using a group teaching method to teach self-management skills improved self-efficacy levels.