Future year (2028) source apportionment modeling to support Regional Haze Rule planning in the western U.S.

The Western Regional Air Partnership (WRAP) has developed a modeling platform to simulate the formation of haze-causing particles that impact federally-protected lands in the western United States. To assist state air quality planners in determining which emission sources are likely candidates for future mitigation, several source apportionment scenarios were evaluated, and two sets of results for the year 2028 are presented here: 1) a "high-level important regional sources" version, with broad emission categories (i.e. U.S. anthropogenic, international anthropogenic, natural, and fires), and 2) a "low-level anthropogenic emission sources within individual states" version, which refines the U.S. anthropogenic contribution to specific emission sectors within individual WRAP region states. Eight examples are discussed, which reflect the variation in source apportionment results at national parks, wilderness areas, and wildlife refuges in the western U.S. and suggest which emission sectors are candidates for mitigation to improve future visibility. In 2028, the contribution of domestic anthropogenic emissions at the eight sites ranges from 17% to 58%, with significant impacts from oil and gas production, fossil fuel electric generation, and federally-regulated mobile sources. The contribution from international anthropogenic sources can also be considerable, and ranges from 17% to 43%. Most sectors that are emitting sulfur dioxide (SO2) and nitrogen oxides (NOx), which are the two most likely particle precursors to be curtailed in the states' Regional Haze plans, are declining. For example, in the 13 contiguous WRAP region states, NOx emissions from on-road mobile sources and electric generating units (EGUs) declined by 738 kton/yr (29% decrease) and 65 kton/yr (31% decrease), respectively, in 2028 as compared to current emission estimates, and SO2 emissions from EGUs declined by 42 kton/yr (29% decrease). NOx emissions from oil and gas development also declined by 25 kton/yr (9% decrease) but rose for SO2 emissions by 12 kton/yr (20% increase).Implications: The goal of the Regional Haze Rule (RHR) is to improve visibility at federally-protected areas, and to eventually arrive at natural conditions by the year 2064. Source apportionment tools within regional air quality models are useful for identifying which emission regions and sectors are contributing to haze-causing particles and can indicate to air quality planners where additional emission controls may be warranted.

Emotional intelligence in undergraduate medical students: a scoping review.

PURPOSE: To perform a scoping review to determine what is known about emotional intelligence (EI) in undergraduate medical education (UME). Two main questions were asked: A. What medical student characteristics are associated with EI? Are there correlations with demographic or other factors? B. What research studies have been done on EI in UME? For example, is there evidence EI changes over time as a result of personal experiences? Should EI be used as an admission criterion? Can EI improve as a result of experiences or deliberate interventions? METHOD: The authors searched four databases (PubMed, PsycInfo, Education Resources Information Center, and Web of Science) for all papers published up to and including December 2020. Two reviewers independently screened articles to determine if they met inclusion criteria. All authors extracted and analyzed data. RESULTS: A set of 1520 papers on the topic of emotional intelligence was identified, with 119 papers meeting inclusion criteria. Most studies were done at international locations with only 17 done at US medical schools. Seventy-five were cohort or cross-sectional studies. Study populations were mixed among the studies, with year of medical study, inclusion of other healthcare students, and participation rates among the inter-study differences noted. CONCLUSIONS: Numerous gaps in the literature on EI exist with several points being clear: (1) there is disagreement on the definition of EI, (2) it is undetermined whether EI is a trait or an ability, and (3) there is marked variability among the instruments used to measure EI. It is also becoming apparent that using EI determination may be helpful as a component of the admission process, higher EI is likely related to improved clinical reasoning, and higher EI contributes to more effective stress management.

Sampling of Patient Radiation Therapy Thermoplastic Immobilization Forms Reveals Several Types of Attached Bacteria.

BACKGROUND: Thermoplastic medical devices used during patient therapy have been shown to harbor microbes, including those causing healthcare-associated infections (HAI). This issue has not been previously evaluated for immobilization forms used during radiation therapy. The present study addresses this matter by sampling immobilization forms used during patient treatment to see if any microbes could be similarly recovered. METHODS: Twelve head-only in-use patient forms were sampled at 3 radiation therapy facilities. Sampled form areas included cheeks, forehead, and nose. A site survey was also conducted to determine individual form characteristics and form handling procedures. RESULTS: All twelve forms demonstrated at least one type of bacteria being recovered from sampled areas, several forms with multiple types. Bacterium was not recovered from the nose area of a single form, even though bacteria were recovered from the same form's cheeks and forehead areas. Recovered bacteria included Bacillus species spp. (21), coagulase-negative staphylococci or CoNS (19), Staphylococcus aureus (2), Enterococcus species (1), alpha-hemolytic (viridians) streptococci (1), and Gram-negative rods (1). Bacillus species spp. and CoNS were recovered from 10 of 12 (∼84%) forms in at least one sampled area. In addition, a single Bacillus spp. was also recovered from a water bath used to heat forms at one treatment facility. DISCUSSION: The detected presence of several bacterial types on patient forms indicates that they can attach to and surviving, for a time, on form surfaces. Two of the bacteria recovered, namely S. aureus and Enterococcus spp. are confirmed HAI pathogens. The remainder are considered as opportunistic bacterial pathogens that can cause HAIs in debilitated patients. Of special concern is the recovery of several different species of the environmental bacterium Bacillus spp. at a higher level than CoNS, a normal skin bacterium. The ability of Bacillus spp. to form spores further enhances its survival capability on form surfaces. The source of the recovered bacteria, including Bacillus spp. was not determined. CONCLUSION: The presence of bacteria on stored patient form surfaces indicates that there is a real potential to transfer them to the patient during its reapplication. The actual potential for microbe transfer such as Bacillus spp. or its spores has yet to be determined. Consequently, care should be taken by radiation therapy personnel in handling forms during patient reapplication. Precautions such as donning a fresh pair of gloves and cleaning a form with an approved disinfectant can help to reduce and/or eliminate unintended microbe transfer to the patient wearing it. This procedure should also be considered for patients without apparent open or leaking wounds.

Air pollutant source characterization using the revised regional haze tracking metric and a photochemical grid model and implications for regional haze planning.

The 2017 revisions to the Regional Haze Rule clarify that visibility progress at Class I national parks and wilderness areas should be tracked on days with the highest anthropogenic contributions to haze (impairment). We compare the natural and anthropogenic contributions to haze in the western United States in 2011 estimated using the Environmental Protection Agency (EPA) recommended method and using model projections from the Comprehensive Air Quality Model with Extensions (CAMx) and the Particulate Source Apportionment Tool (PSAT). We do so because these two methods will be used by states to demonstrate visibility progress by 2028. If the two methods assume different natural and anthropogenic contributions, the projected benefits of reducing U.S. anthropogenic emissions will differ. The EPA method assumes that episodic elevated carbonaceous aerosols greater than an annual 95th percentile threshold are natural events. For western U.S. IMPROVE monitoring sites reviewed in this paper, CAMx-PSAT confirms these episodes are impacted by carbon from wildfire or prescribed fire events. The EPA method assumes that most of the ammonium sulfate is anthropogenic in origin. At most western sites CAMx-PSAT apportions more of the ammonium sulfate on the most impaired days to global boundary conditions and anthropogenic Canadian, Mexican, and offshore shipping emissions than to U.S. anthropogenic sources. For ammonium nitrate and coarse mass, CAMx-PSAT apportions greater contributions to U.S. anthropogenic sources than the EPA method assigns to total anthropogenic contributions. We conclude that for western IMPROVE sites, the EPA method is effective in selecting days that are likely to be impacted by anthropogenic emissions and that CAMx-PSAT is an effective approach to estimate U.S. source contributions. Improved inventories, particularly international and natural emissions, and further evaluation of global and regional model performance and PSAT attribution methods are recommended to increase confidence in modeled source characterization. Implications: The western states intend to use the CAMx model to project visibility progress by 2028. Modeled visibility response to changes in U.S. anthropogenic emissions may be less than estimated using the EPA assumptions based on total U.S. and international anthropogenic contributions to visibility impairment. Additional model improvements are needed to better account for contributions to haze from natural and international emissions in current and future modeling years. These improvements will allow more direct comparison of model and EPA estimates of natural and anthropogenic contributions to haze and future visibility progress.

Investing in success: student experiences in a structured, decelerated preclinical medical school curriculum.

PURPOSE: Many students in the Michigan State University College of Human Medicine (CHM) are non-traditional with unique needs and experiences. To meet these needs, in 1988 CHM developed a structured Extended Curriculum Program (ECP), which allows students to take longer than 2 years to complete the preclinical curriculum. This work examined the reasons why students extended their programs, their perceptions of that experience, and the outcome with respect to satisfaction and success in their careers after graduation. METHODS: The analysis used data from the college database, follow-up surveys of residency directors and graduates, surveys of graduates who extended, and the AMA Physician Masterfile. RESULTS: Graduates who responded to the survey were evenly split between those who extended for academic reasons and those who extended for other reasons. Although feelings about extending were mixed at the time of extension, nearly all respondents agreed that extending was the right decision in the long run. Extended students continued to face academic challenges having lower basic science averages, lower USMLE Step 1 and 2 first attempt pass rates, and more instances of repeated clerkships compared to those who did not extend, however, most were able to secure a residency in the specialty they desired and had comparable career satisfaction ratings. CONCLUSIONS: The ECP allows some students to complete medical school who otherwise may not have been able to do so. This analysis has provided valuable information that was used to improve the program, allowing CHM to continue its mission of training a diverse set of students to be exemplary physicians.

Source contributions to visibility impairment in the southeastern and western United States.

The 1999 Regional Haze Rule requires states to complete comprehensive technical analyses of air pollutants that impair visibility and to define long-term strategies to improve visibility in the nation's 156 visibility-protected federal Class I national parks and wilderness areas. Class I areas in the southeastern United States are among the most impacted in the country; fine particle loadings in the western United States are a fraction of those in the East. In the Southeast, (NH4)2SO4 (ammonium sulfate) predominantly from SO2 (sulfur dioxide) emissions from electric generating utilities and industrial sources contributes 60-70% of the light extinction on the 20% haziest days; particulate organic matter (POM) predominantly from biogenic emissions and biomass burning is the second largest contributor. In the West, the mix of source contributions is more complex. At Class I areas downwind of major urban areas (e.g., California), ammonium nitrate (NH4NO3), predominantly because of mobile sources, is the dominant contributor to haze. For many western Class L areas, POM from wildland fires and fine particles from windblown dust, largely uncontrollable sources, are significant contributors to haze. International emissions are an additional uncontrollable and significant contribution to total sulfate (SO4) and nitrate (NO3) concentrations at the western Class I areas. In the Southeast, SO2 emissions reductions are projected to result in nearly 1:1 regional SO4 reductions; oxides of nitrogen (NO(x)) emissions reductions have minimal impact on NO3 concentrations and haze. In the West, SO2 emissions reductions result in incremental SO4 reductions, whereas mobile NO(x) emissions reductions are projected to reduce NO3 and improve visibility at Class I areas affected by urban areas. Because wildfire, dust, and international emissions have large contributions to the haziest days and are mostly uncontrollable in the West, reductions from anthropogenic sources in the West have less effect in improving visibility compared with the Southeast.

Quantifying the sources of ozone, fine particulate matter, and regional haze in the Southeastern United States.

A detailed sensitivity analysis was conducted to quantify the contributions of various emission sources to ozone (O3), fine particulate matter (PM2.5), and regional haze in the Southeastern United States. O3 and particulate matter (PM) levels were estimated using the Community Multiscale Air Quality (CMAQ) modeling system and light extinction values were calculated from modeled PM concentrations. First, the base case was established using the emission projections for the year 2009. Then, in each model run, SO2, primary carbon (PC), NH3, NO(x) or VOC emissions from a particular source category in a certain geographic area were reduced by 30% and the responses were determined by calculating the difference between the results of the reduced emission case and the base case. The sensitivity of summertime O3 to VOC emissions is small in the Southeast and ground-level NO(x) controls are generally more beneficial than elevated NO(x) controls (per unit mass of emissions reduced). SO2 emission reduction is the most beneficial control strategy in reducing summertime PM2.5 levels and improving visibility in the Southeast and electric generating utilities are the single largest source of SO2. Controlling PC emissions can be very effective locally, especially in winter. Reducing NH3 emissions is an effective strategy to reduce wintertime ammonium nitrate (NO3NH4) levels and improve visibility; NO(x) emissions reductions are not as effective. The results presented here will help the development of specific emission control strategies for future attainment of the National Ambient Air Quality Standards in the region.

A new model to facilitate palpation of the level of the transverse processes of the thoracic spine.

STUDY DESIGN: Nonexperimental, normative research design. OBJECTIVES: To test a proposed model to locate the level of the transverse processes (TPs) of the thoracic spine through surface palpation. BACKGROUND: Palpation of the TPs of the thoracic spine is challenging because of their depth relative to the more superficial structures of the spine. Many clinicians use the more superficial spinous processes (SPs) of the thoracic spine to orient themselves for palpation of the TPs. In 1979, Mitchell described a "rule of threes," which attempted to predict the location of the level of the thoracic TPs relative to their corresponding SPs. We previously conducted a pilot study to investigate the validity of the rule of threes and concluded that it is not an accurate predictor of the level of the location of the TPs of the thoracic spine. Based on that previous work, we hypothesized that a more accurate model for predicting the level of the TPs would be that they are generally at the level of the SP of the adjacent cranial thoracic vertebra throughout the thoracic spine. METHODS AND MEASURES: We dissected 15 cadavers and measured the vertical distance between the transverse (horizontal) plane of the TPs of 1 vertebra and the SP of the adjacent cranial thoracic vertebra for all levels of the thoracic spine. RESULTS: Mean vertical distances ranged from 2.0 to 4.0 mm. The means for all thoracic vertebral levels except for T11 and T12 were significantly less than the normal 6-mm threshold of 2-point discrimination of the fingertips (P<.01). CONCLUSION: The results of this study indicate that the TPs of each thoracic vertebra are generally at the level of the SP of the vertebra 1 level above, throughout the thoracic spine. It may be more difficult to predict the location of the TPs of the 2 most caudal levels (T11 and T12), given their greater variability of position.

Natural background visibility and regional haze goals in the Southeastern United States.

The goal of the regional haze mitigation program in the United States is to attain "natural conditions" in national parks and wilderness areas by 2064. Results of research investigations on background concentrations of sea salt and biogenic organic matter, of episodic Saharan and Asian dust, and of carbon from natural fires were reviewed to provide a basis for making site-specific estimates of what the concentrations of atmospheric fine particulate matter components might be under natural conditions in the Southeastern United States. Based on this review, rough estimates were made of potential contributions of these aerosol components to natural background visibility. Natural organic particles were the dominant influence on the rate of visibility improvement required to reach natural conditions at an inland, mountainous location, and organic particles and sea salt were the dominant influences on the rate at a coastal location. African dust also had a large episodic effect, but the current regulatory approach is not designed to address episodic background variations. Insufficient data exist to quantify the contributions of wildfires with any detail, although global air pollution modeling provides insight, and their emissions can be locally dominant. Conservative regional refinements to the default natural background estimates do not greatly alter the region-wide rates of reduction of ambient particulate matter concentrations that will be needed to accomplish the first phase of the regional haze program. However, refinements at specific Class I areas may have considerable influence on defining the nature (magnitude and spatial and temporal distribution) of local emission reduction efforts there.

Trends in speciated fine particulate matter and visibility across monitoring networks in the Southeastern United States.

Trends in fine particulate matter <2.5 microm in diameter (PM2.5) and visibility in the Southeastern United States were evaluated for sites in the Interagency Monitoring of Protected Visual Environments, Speciated Trends Network, and Southeastern Aerosol Research and Characterization Study networks. These analyses are part of the technical assessment by Visibility Improvement-State and Tribal Association of the Southeast (VISTAS), the regional planning organization for the southeastern states, in support of State Implementation Plans for the regional haze rule. At all of the VISTAS IMPROVE sites, ammonium sulfate and organic carbon (OC) are the largest and second largest contributors, respectively, to light extinction on both the 20% haziest and 20% clearest days. Ammonium nitrate, elemental carbon (EC), soils, and coarse particles make comparatively small contributions to PM2.5 mass and light extinction on most days at the Class I areas. At Southern Appalachian sites, the 20% haziest days occur primarily in the late spring to fall, whereas at coastal sites, the 20% haziest days can occur through out the year. Levels of ammonium sulfate in Class I areas are similar to those in nearby urban areas and are generally higher at the interior sites than the coastal sites. Concentrations of OC, ammonium nitrate, and, sometimes, EC, tend to be higher in the urban areas than in nearby Class I areas, although differences in measurement methods complicate comparisons between networks. Results support regional controls of sulfur dioxide for both regional haze and PM2.5 implementation and suggest that controls of local sources of OC, EC, or nitrogen oxides might also be considered for urban areas that are not attaining the annual National Ambient Air Quality Standard for PM2.5.

Preliminary evaluation of the Community Multiscale Air Quality model for 2002 over the Southeastern United States.

The Visibility Improvement State and Tribal Association of the Southeast (VISTAS) is one of five Regional Planning Organizations that is charged with the management of haze, visibility, and other regional air quality issues in the United States. The VISTAS Phase I work effort modeled three episodes (January 2002, July 1999, and July 2001) to identify the optimal model configuration(s) to be used for the 2002 annual modeling in Phase II. Using model configurations recommended in the Phase I analysis, 2002 annual meteorological (Mesoscale Meterological Model [MM5]), emissions (Sparse Matrix Operator Kernal Emissions [SMOKE]), and air quality (Community Multiscale Air Quality [CMAQ]) simulations were performed on a 36-km grid covering the continental United States and a 12-km grid covering the Eastern United States. Model estimates were then compared against observations. This paper presents the results of the preliminary CMAQ model performance evaluation for the initial 2002 annual base case simulation. Model performance is presented for the Eastern United States using speciated fine particle concentration and wet deposition measurements from several monitoring networks. Initial results indicate fairly good performance for sulfate with fractional bias values generally within +/-20%. Nitrate is overestimated in the winter by approximately +50% and underestimated in the summer by more than -100%. Organic carbon exhibits a large summer underestimation bias of approximately -100% with much improved performance seen in the winter with a bias near zero. Performance for elemental carbon is reasonable with fractional bias values within +/- 40%. Other fine particulate (soil) and coarse particular matter exhibit large (80-150%) overestimation in the winter but improved performance in the summer. The preliminary 2002 CMAQ runs identified several areas of enhancements to improve model performance, including revised temporal allocation factors for ammonia emissions to improve nitrate performance and addressing missing processes in the secondary organic aerosol module to improve OC performance.