Substantial increase in perfluorocarbons CF4 (PFC-14) and C2F6 (PFC-116) emissions in China.

The perfluorocarbons tetrafluoromethane (CF4, PFC-14) and hexafluoroethane (C2F6, PFC-116) are potent greenhouse gases with near-permanent atmospheric lifetimes relative to human timescales and global warming potentials thousands of times that of CO2. Using long-term atmospheric observations from a Chinese network and an inverse modeling approach (top-down method), we determined that CF4 emissions in China increased from 4.7 (4.2-5.0, 68% uncertainty interval) Gg y-1 in 2012 to 8.3 (7.7-8.9) Gg y-1 in 2021, and C2F6 emissions in China increased from 0.74 (0.66-0.80) Gg y-1 in 2011 to 1.32 (1.24-1.40) Gg y-1 in 2021, both increasing by approximately 78%. Combined emissions of CF4 and C2F6 in China reached 78 Mt CO2-eq in 2021. The absolute increase in emissions of each substance in China between 2011-2012 and 2017-2020 was similar to (for CF4), or greater than (for C2F6), the respective absolute increase in global emissions over the same period. Substantial CF4 and C2F6 emissions were identified in the less-populated western regions of China, probably due to emissions from the expanding aluminum industry in these resource-intensive regions. It is likely that the aluminum industry dominates CF4 emissions in China, while the aluminum and semiconductor industries both contribute to C2F6 emissions. Based on atmospheric observations, this study validates the emission magnitudes reported in national bottom-up inventories and provides insights into detailed spatial distributions and emission sources beyond what is reported in national bottom-up inventories.

Increases in Global and East Asian Nitrogen Trifluoride (NF3) Emissions Inferred from Atmospheric Observations.

Nitrogen trifluoride (NF3) is a potent and long-lived greenhouse gas that is widely used in the manufacture of semiconductors, photovoltaic cells, and flat panel displays. Using atmospheric observations from eight monitoring stations from the Advanced Global Atmospheric Gases Experiment (AGAGE) and inverse modeling with a global 3-D atmospheric chemical transport model (GEOS-Chem), we quantify global and regional NF3 emission from 2015 to 2021. We find that global emissions have grown from 1.93 ± 0.58 Gg yr-1 (± one standard deviation) in 2015 to 3.38 ± 0.61 Gg yr-1 in 2021, with an average annual increase of 10% yr-1. The available observations allow us to attribute significant emissions to China (0.93 ± 0.15 Gg yr-1 in 2015 and 1.53 ± 0.20 Gg yr-1 in 2021) and South Korea (0.38 ± 0.07 Gg yr-1 to 0.65 ± 0.10 Gg yr-1). East Asia contributes around 73% of the global NF3 emission increase from 2015 to 2021: approximately 41% of the increase is from emissions from China (with Taiwan included), 19% from South Korea, and 13% from Japan. For Japan, which is the only one of these three countries to submit annual NF3 emissions to UNFCCC, our bottom-up and top-down estimates are higher than reported. With increasing demand for electronics, especially flat panel displays, emissions are expected to further increase in the future.

Rising Perfluorocyclobutane (PFC-318, c-C4F8) Emissions in China from 2011 to 2020 Inferred from Atmospheric Observations.

Global atmospheric emissions of perfluorocyclobutane (c-C4F8, PFC-318), a potent greenhouse gas, have increased rapidly in recent years. Combining atmospheric observations made at nine Chinese sites with a Lagrangian dispersion model-based Bayesian inversion technique, we show that PFC-318 emissions in China grew by approximately 70% from 2011 to 2020, rising from 0.65 (0.54-0.72) Gg year-1 in 2011 to 1.12 (1.05-1.19) Gg year-1 in 2020. The PFC-318 emission increase from China played a substantial role in the overall increase in global emissions during the study period, contributing 58% to the global total emission increase. This growth predominantly originated in eastern China. The regions with high emissions of PFC-318 in China overlap with areas densely populated with polytetrafluoroethylene (PTFE) factories, implying that fluoropolymer factories are important sources of PFC-318 emissions in China. Our investigation reveals an emission factor of approximately 3.02 g of byproduct PFC-318 emissions per kg of hydrochlorofluorocarbon-22 (HCFC-22) feedstock use in the production of tetrafluoroethylene (TFE) (for PTFE production) and hexafluoropropylene (HFP) if we assume all HCFC-22 produced for feedstock uses in China are pyrolyzed to produce PTFE and HFP. Further facility-level sampling and analysis are needed for a more precise evaluation of emissions from these factories.

Construct validation of a novel synthetic tendon model used for assessing surgeon performance in a simulated core suture tendon repair technique.

BACKGROUND: The strength of tendon repair is dependent on the quality of the core suture. Organic and synthetic materials have been used to simulate tendon repair for training; however, no model has undergone construct validation. OBJECTIVES: To determine the construct validity of a novel synthetic tendon repair model. METHODS: Synthetic silicone tendon models were used to simulate adult Achilles tendon (AT) and digital flexor tendon (FT). Participants were categorised into novice, intermediate, and advanced groups based on prior surgical experience. Participants repaired tendons using the modified Kessler technique. A validated motion analysis system was used to measure the duration, path length, and movement count during the simulated task. A global rating score was also used to assess the performance. RESULTS: All participants in the novice (n = 12), intermediate (n = 8) and advanced (n = 11) groups completed the tasks. The results (mean±standard deviation) were duration (872 ± 335, 492 ± 257 and 357 ± 40 s), path length (9493 ± 3173, 6668 ± 1740 and 4672 ± 1228 cm), movement count (4974 ± 673, 4228 ± 259 and 3962 ± 69) and global rating (39 ± 13, 61 ± 14, 81 ± 5), respectively. The Kruskal-Wallis test was significant for all outcome measures (p < 0.01). Significant differences in duration and movement count were identified post-hoc in the AT model for each experience group (p < 0.05), and between novice and intermediate participants for FT repair (p < 0.04). Global rating was significantly different between all groups and was highly correlated with motion metrics (p < 0.01). CONCLUSION: The results support construct validity of this novel simulated tendon repair model. The global rating scores may allow wide utility of this simulation. This model provides a valid and safe environment for surgical trainees to practice tendon repair with several cost, ethical and logistical benefits over animal tendon use. 248/250.

Sustained growth of sulfur hexafluoride emissions in China inferred from atmospheric observations.

Sulfur hexafluoride (SF6) is a potent greenhouse gas. Here we use long-term atmospheric observations to determine SF6 emissions from China between 2011 and 2021, which are used to evaluate the Chinese national SF6 emission inventory and to better understand the global SF6 budget. SF6 emissions in China substantially increased from 2.6 (2.3-2.7, 68% uncertainty) Gg yr-1 in 2011 to 5.1 (4.8-5.4) Gg yr-1 in 2021. The increase from China is larger than the global total emissions rise, implying that it has offset falling emissions from other countries. Emissions in the less-populated western regions of China, which have potentially not been well quantified in previous measurement-based estimates, contribute significantly to the national SF6 emissions, likely due to substantial power generation and transmission in that area. The CO2-eq emissions of SF6 in China in 2021 were 125 (117-132) million tonnes (Mt), comparable to the national total CO2 emissions of several countries such as the Netherlands or Nigeria. The increasing SF6 emissions offset some of the CO2 reductions achieved through transitioning to renewable energy in the power industry, and might hinder progress towards achieving China's goal of carbon neutrality by 2060 if no concrete control measures are implemented.

Anthropogenic Chloroform Emissions from China Drive Changes in Global Emissions.

Emissions of chloroform (CHCl3), a short-lived halogenated substance not currently controlled under the Montreal Protocol on Substances that Deplete the Ozone Layer, are offsetting some of the achievements of the Montreal Protocol. In this study, emissions of CHCl3 from China were derived by atmospheric measurement-based "top-down" inverse modeling and a sector-based "bottom-up" inventory method. Top-down CHCl3 emissions grew from 78 (72-83) Gg yr-1 in 2011 to a maximum of 193 (178-204) Gg yr-1 in 2017, followed by a decrease to 147 (138-154) Gg yr-1 in 2018, after which emissions remained relatively constant through 2020. The changes in emissions from China could explain all of the global changes during the study period. The CHCl3 emissions in China were dominated by anthropogenic sources, such as byproduct emissions during disinfection and leakage from chloromethane industries. Had emissions continued to grow at the rate observed up to 2017, a delay of several years in Antarctic ozone layer recovery could have occurred. However, this delay will be largely avoided if global CHCl3 emissions remain relatively constant in the future, as they have between 2018 and 2020.

In Situ Observations of Halogenated Gases at the Shangdianzi Background Station and Emission Estimates for Northern China.

Halogenated gases include ozone-depleting substances and greenhouse gases, such as chlorofluorocarbons, halons, hydrochlorofluorocarbons, hydrofluorocarbons, and perfluorinated gases. In situ atmospheric observations of major halogenated gases were conducted at the Shangdianzi (SDZ) background station, China, from October 2020 to September 2021 using ODS5-pro, a newly developed measurement system. The measurement time series of 36 halogenated gases showed occasional pollution events, where background conditions represented 25% (CH2Cl2) to 81% (CF3Cl, CFC-13) of the measurements. The annual mean background mole fractions of most species at SDZ were consistent with those obtained at the Mace Head station in Ireland. The background conditions were distinguished from pollution events, and the enhanced mole fractions were used to estimate the emissions of four categories of fluorinated gases (F-gases) from northern China using a tracer ratio method. The CO2-equivalent (CO2-equiv) emission of F-gases from northern China reached 181 ± 18 Tg year-1 during 2020-2021. Among the four categories of F-gases estimated, SF6 accounted for the highest proportion of CO2-equiv emissions (24%), followed by HFC-23 (22%), HFC-125 (17%), HFC-134a (13%), NF3 (10%), CF4 (5.9%), HFC-143a (3.9%), HFC-32 (3.4%), and HFC-152a (0.2%).

A webinar series to educate applicants about the UK academic foundation programme: a longitudinal cross-sectional study.

BACKGROUND: The UK academic foundation programme (AFP) is a competitive programme for medical graduates and forms the initial stage of the integrated clinical academic pathway. The application is complex and targeted education is beneficial. As online technologies improve, virtual medical education is becoming more common. Currently, webinar education, particularly that of webinar series, are poorly evidenced. An online course was created to investigate the acceptability and effectiveness of webinars for medical education. METHODS: A six-part, one-hour sessional webinar course was developed following a focus group with academic foundation doctors. A pre- and post-course cross-sectional questionnaire study evaluated participant demographics, webinar opinion and self-rated understanding of the AFP via Google Form (Google, USA). Where applicable a five-point Likert scale (1-Strongly disagree to 5-strongly agree) was utilised and analysis using non-parametric paired statistical analysis. RESULTS: Medical students (n=303) from 35 UK universities completed the pre-course questionnaire. Most students had not received targeted education on the AFP. They rated webinars useful for education (mean=4.2 s.d. 0.7). After the course, participants (n=66) expressed it was significantly convenient (mean=4.7), effective (mean=4.7) and suitably interactive (mean=4.4) (p<0.001 compared to neutral). Participants preferred short sessions over multiple days to the concept of a full-day event (mean=4.6 vs 3.1, p<0.001). Paired analysis of participants completing both forms (n=47) demonstrates a significant increase in self-rated understanding of AFP content, portfolio building, application process, acute clinical scenarios, interview technique and overall confidence in acquiring an AFP post (p<0.001). Follow-up identified 43 participants who completed the course were successful in their AFP application. This represents 7.8% of all successful AFP applicants in 2021. CONCLUSIONS: This study evidences an accessible and effective webinar series for AFP education. Comprehensive webinar courses for similar topics and demographics may provide valuable utility in the provision of future medical education. TRIAL REGISTRATION: Ethics requirements were waived for this study by Bristol University Ethics Committee. All participants in this study consented for anonymous use of their data. As such the trial is not registered.

Rapid increase in dichloromethane emissions from China inferred through atmospheric observations.

With the successful implementation of the Montreal Protocol on Substances that Deplete the Ozone Layer, the atmospheric abundance of ozone-depleting substances continues to decrease slowly and the Antarctic ozone hole is showing signs of recovery. However, growing emissions of unregulated short-lived anthropogenic chlorocarbons are offsetting some of these gains. Here, we report an increase in emissions from China of the industrially produced chlorocarbon, dichloromethane (CH2Cl2). The emissions grew from 231 (213-245) Gg yr-1 in 2011 to 628 (599-658) Gg yr-1 in 2019, with an average annual increase of 13 (12-15) %, primarily from eastern China. The overall increase in CH2Cl2 emissions from China has the same magnitude as the global emission rise of 354 (281-427) Gg yr-1 over the same period. If global CH2Cl2 emissions remain at 2019 levels, they could lead to a delay in Antarctic ozone recovery of around 5 years compared to a scenario with no CH2Cl2 emissions.

Bone Tumours of the Talus: 18-Year Cohort of Patients With Rare Osteoid Lesions.

Background Bone tumours of the talus are a rare cause of ankle pain. This study aims to provide additional clinical clarity regarding the presentation and management of a minimally researched topic. Methods Sixteen patients were diagnosed with bone tumour of the talus between 2002 and 2020 following referral for ankle pain. Symptoms, diagnosis, and management were retrospectively reviewed. Patients were actively followed up until consistently symptom-free and consenting to discharge (mean of 2.9 years). An open appointment was offered to all patients to reattend the unit if symptoms recurred. Results The most common diagnosis was osteoid osteoma/osteoblastoma (nine patients), chondroblastoma (four patients), a giant cell tumour of bone, a chondral lesion in Ollier's disease and a rare metastatic renal cancer case. The mean age of onset was 29 years. Thirteen patients experienced ankle pain without a clear precipitating cause. Night pain was less common in osteoid osteoma/osteoblastoma than usually observed in the literature. The mean delay in diagnosis was two years, often due to an incorrect diagnosis of soft tissue injury. Plain radiographs are insufficient to identify most lesions. Ten patients underwent computed tomography (CT)-guided radiofrequency ablation and five patients had open surgical curettage. Ollier's disease was managed with orthotics. The five cases of recurrence across four patients were managed operatively. Conclusions Patients are usually young and healthy with benign disease, but talus tumours can cause significant functional impairment. Unexplained ankle pain should be extensively examined and be further investigated with magnetic resonance imaging (MRI) and CT scanning to avoid missing these rare tumours.

A decline in emissions of CFC-11 and related chemicals from eastern China.

Emissions of ozone-depleting substances, including trichlorofluoromethane (CFC-11), have decreased since the mid-1980s in response to the Montreal Protocol1,2. In recent years, an unexpected increase in CFC-11 emissions beginning in 2013 has been reported, with much of the global rise attributed to emissions from eastern China3,4. Here we use high-frequency atmospheric mole fraction observations from Gosan, South Korea and Hateruma, Japan, together with atmospheric chemical transport-model simulations, to investigate regional CFC-11 emissions from eastern China. We find that CFC-11 emissions returned to pre-2013 levels in 2019 (5.0 ± 1.0 gigagrams per year in 2019, compared to 7.2 ± 1.5 gigagrams per year for 2008-2012, ±1 standard deviation), decreasing by 10 ± 3 gigagrams per year since 2014-2017. Furthermore, we find that in this region, carbon tetrachloride (CCl4) and dichlorodifluoromethane (CFC-12) emissions-potentially associated with CFC-11 production-were higher than expected after 2013 and then declined one to two years before the CFC-11 emissions reduction. This suggests that CFC-11 production occurred in eastern China after the mandated global phase-out, and that there was a subsequent decline in production during 2017-2018. We estimate that the amount of the CFC-11 bank (the amount of CFC-11 produced, but not yet emitted) in eastern China is up to 112 gigagrams larger in 2019 compared to pre-2013 levels, probably as a result of recent production. Nevertheless, it seems that any substantial delay in ozone-layer recovery has been avoided, perhaps owing to timely reporting3,4 and subsequent action by industry and government in China5,6.

Summary and recommendations from the workshop 'Integrating measurements and atmospheric-dispersion modelling to enhance the UK response to radiological atmospheric releases'.

Effective preparedness and response to an atmospheric release following a radiological incident relies on information concerning the source, transport and eventual removal of the contaminant. A notable improvement to emergency preparedness and response in the UK to airborne releases of radiological contaminants can be achieved through the integration of information sources, in particular environmental radiological measurements and atmospheric-dispersion modelling. A one-day workshop was organised by the UK Met Office and the University of Bristol, comprising private nuclear facility operators, public bodies, academia and others, on 6 February 2020 in Bristol, UK. The workshop reviewed the current capabilities and challenges of measurements and modelling of airborne radiological contaminants and their integration, and identified improvement pathways. This memorandum provides a summary of recommendations from the workshop.

Emissions and Marine Boundary Layer Concentrations of Unregulated Chlorocarbons Measured at Cape Point, South Africa.

Unregulated chlorocarbons, here defined as dichloromethane (CH2Cl2), perchloroethene (C2Cl4), chloroform (CHCl3), and methyl chloride (CH3Cl), are gases not regulated by the Montreal Protocol. While CH3Cl is the largest contributor of atmospheric chlorine, recent studies have shown that growth in emissions of the less abundant chlorocarbons could pose a significant threat to the recovery of the ozone layer. Despite this, there remain many regions for which no atmospheric monitoring exists, leaving gaps in our understanding of global emissions. Here, we report on a new time series of chlorocarbon measurements from Cape Point, South Africa for 2017, which represent the first published high-frequency measurements of these gases from Africa. For CH2Cl2 and C2Cl4, the majority of mole fraction enhancements were observed from the north, consistent with anthropogenically modified air from Cape Town, while for CHCl3 and CH3Cl, we found evidence for both oceanic and terrestrial sources. Using an inverse method, we estimated emissions for south-western South Africa (SWSA). For each chlorocarbon, SWSA accounted for less than 1% of global emissions. For CH2Cl2 and C2Cl4, we extrapolated using population statistics and found South African emissions of 8.9 (7.4-10.4) Gg yr-1 and 0.80 (0.64-1.04) Gg yr-1, respectively.

Source estimation of an unexpected release of Ruthenium-106 in 2017 using an inverse modelling approach.

For the first time since the Chernobyl accident, detectable concentrations of ruthenium-106 were measured across Europe in September and October 2017. The source of this radioactive cloud remains unconfirmed. In this paper we present a forensic inverse modelling study to simultaneously estimate the source location, timing and magnitude of the unexpected ruthenium-106 release using 473 measurements of atmospheric concentration. To do this, we introduce a novel method, which estimates the uncertainty in the often unknown transport error using a Markov chain Monte Carlo approach. We corroborate the conclusions of other studies which suggest the source location is in the Southern Ural region of Russia, where the Mayak nuclear complex is located. Assuming that the Mayak nuclear complex is the most plausible release location, the method estimates that 441±13 TBq was released 12:00-18:00 UTC 24 September 2017, assuming a six hour release window.

Can an Augmented Reality Headset Improve Accuracy of Acetabular Cup Orientation in Simulated THA? A Randomized Trial.

BACKGROUND: Accurate implant orientation reduces wear and increases stability in arthroplasty but is a technically demanding skill. Augmented reality (AR) headsets overlay digital information on top of the real world. We have developed an enhanced AR headset capable of tracking bony anatomy in relation to an implant, but it has not yet been assessed for its suitability as a training tool for implant orientation. QUESTIONS/PURPOSES: (1) In the setting of simulated THA performed by novices, does an AR headset improve the accuracy of acetabular component positioning compared with hands-on training by an expert surgeon? (2) What are trainees' perceptions of the AR headset in terms of realism of the task, acceptability of the technology, and its potential role for surgical training? METHODS: Twenty-four study participants (medical students in their final year of school, who were applying to surgery residency programs, and who had no prior arthroplasty experience) participated in a randomized simulation trial using an AR headset and a simulated THA. Participants were randomized to two groups completing four once-weekly sessions of baseline assessment, training, and reassessment. One group trained using AR (with live holographic orientation feedback) and the other received one-on-one training from a hip arthroplasty surgeon. Demographics and baseline performance in orienting an acetabular implant to six patient-specific values on the phantom pelvis were collected before training and were comparable. The orientation error in degrees between the planned and achieved orientations was measured and was not different between groups with the numbers available (surgeon group mean error ± SD 16° ± 7° versus AR 14° ± 7°; p = 0.22). Participants trained by AR also completed a validated posttraining questionnaire evaluating their experiences. RESULTS: During the four training sessions, participants using AR-guidance had smaller mean (± SD) errors in orientation than those receiving guidance from the surgeon: 1° ± 1° versus AR 6° ± 4°, p < 0.001. In the fourth session's assessment, participants in both groups had improved (surgeon group mean improvement 6°, 95% CI, 4-8°; p < 0.001 versus AR group 9°, 95% CI 7-10°; p < 0.001). There was no difference between participants in the surgeon-trained and AR-trained group: mean difference 1.2°, 95% CI, -1.8 to 4.2°; p = 0.281. In posttraining evaluation, 11 of 12 participants would use the AR platform as a training tool for developing visuospatial skills and 10 of 12 for procedure-specific rehearsals. Most participants (11 of 12) stated that a combination of an expert trainer for learning and AR for unsupervised training would be preferred. CONCLUSIONS: A novel head-mounted AR platform tracked an implant in relation to bony anatomy to a clinically relevant level of accuracy during simulated THA. Learners were equally accurate, whether trained by AR or a surgeon. The platform enabled the use of real instruments and gave live feedback; AR was thus considered a feasible and valuable training tool as an adjunct to expert guidance in the operating room. Although there were no differences in accuracy between the groups trained using AR and those trained by an expert surgeon, we believe the tool may be useful in education because it demonstrates that some motor skills for arthroplasty may be learned in an unsupervised setting. Future studies will evaluate AR-training for arthroplasty skills other than cup orientation and its transfer validity to real surgery. LEVEL OF EVIDENCE: Level I, therapeutic study.