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Abstract We derive the generalized second law (GSL) for arbitrary cuts of Killing horizons from the perspective of crossed-product gravitational algebras, making use of a recent proposal by one of us for the construction of local gravitational algebras. This construction relies on the existence of a state whose modular flow is geometric on the horizon. In both free and interacting quantum field theories, such states are guaranteed to exist by the properties of half-sided translations on the horizon. Using geometric identities derived from the canonical analysis of general relativity on null surfaces, we show that the crossed product entropy agrees with the generalized entropy of the horizon cut in a semiclassical limit, and further reproduce Wall’s result relating the GSL to monotonicity of relative entropy of the quantum field algebras. We also give a novel generalization of the GSL for interacting theories in asymptotically flat spacetimes involving the concept of an algebra at infinity for a half-sided translation, which accounts for triviality of the algebra of fields smeared only on the horizon. Going beyond the semiclassical limit, we compute subleading corrections to the crossed product entropy, but are unable to determine if the GSL continues to hold after accounting for these. We speculate that an improved GSL could follow from a hidden subalgebra structure of the crossed products, assuming the existence of an operator-valued weight between horizon cut algebras.

Abstract Scarcity of iron and manganese limits the efficiency of the biological carbon pump over large areas of the Southern Ocean. The importance of hydrothermal vents as a source of these micronutrients to the euphotic zone of the Southern Ocean is debated. Here we present full depth profiles of dissolved and total dissolvable trace metals in the remote eastern Pacific sector of the Southern Ocean (55–60° S, 89.1° W), providing evidence of enrichment of iron and manganese at depths of 2000–4000 m. These enhanced micronutrient concentrations were co-located with 3He enrichment, an indicator of hydrothermal fluid originating from ocean ridges. Modelled water trajectories revealed the understudied South East Pacific Rise and the Pacific Antarctic Ridge as likely source regions. Additionally, the trajectories demonstrate pathways for these Southern Ocean hydrothermal ridge-derived trace metals to reach the Southern Ocean surface mixed layer within two decades, potentially supporting a regular supply of micronutrients to fuel Southern Ocean primary production.

Background and purpose: We aimed to compare the effect of calcium sulphate (CS) beads loaded with antibiotics on infection eradication in debridement, antibiotics, and implant retention (DAIR) of periprosthetic joint infection relative to DAIR without local antibiotics delivery. Methods: 176 patients with hip or knee arthroplasty undergoing DAIR were retrospectively identified and divided into a bead group (n = 102) and a control group (n = 74). Infections were classified as early postoperative, acute hematogenous, and chronic. Logistic regression analyses were performed on the use of CS beads. Revision-free and infection-free survival was estimated using Kaplan–Meier analysis. Results: Reinfection occurred in 36% of the bead group, and 39% of the control group (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.5– 1.6); reoperation rates were 34% and 43% (OR 0.7, CI 0.4–1.3). Kaplan–Meier analysis showed no statistically significant difference between the 2 groups regarding infection-free (HR 1.1, CI 0.7–1.8) and revision-free (HR 1.1, CI 0.7–1.9) survival rates. In acute hematogenous PJIs, reinfection (29% vs 56%, OR 0.3, CI 0.1–1.1) and reoperation rates (25% vs 61%, OR 0.2, CI 0.1–0.8) were reduced when CS beads were used; Kaplan–Meier analysis revealed higher infection-free (HR 0.5, CI 0.2–1.4) and revision-free (HR 0.5, CI 0.2–1.3) survival rates in the bead group but not of statistical significance. Wound drainage was not increased by CS beads use (OR 1.0, CI 0.99–1.01), but hypercalcemia was seen in 9% in the bead group. Conclusion: DAIR with antibiotic-loaded CS beads did not improve outcome in early postoperative and chronic PJIs, but reduced the reoperation rate in acute haematogenous infections with similar results compared with early postoperative PJIs.

Biochar, formed through the pyrolysis or burning of organic wastes, has a complex chemical composition influenced by feedstock, pyrolysis temperature, and reaction conditions. Water-soluble, dissolved black carbon species released from biochar comprise one of the most photoreactive organic matter fractions. Photodegradation of these water-soluble species from wheat straw biochar, produced at different pyrolysis temperatures in laboratory microcosms, resulted in noticeable compositional differences. This study characterized water-soluble transformation products formed through the photodegradation of wheat straw biochar pyrolyzed at 300, 400, 500, or 600°C by electrospray ionization 21 ​T Fourier transform ion cyclotron resonance mass spectrometry (21T FT-ICR MS). We also evaluated global trends in the toxicity of these water-soluble fractions using MicroTox™ to assess the impacts of pyrolysis temperature. Additionally, we examined biochar surface morphology after photodegradation and observed minimal change after irradiation for 48 ​h, though the total yield of water-soluble biochar species varied with pyrolysis temperature. Trends in toxicity observed from MicroTox® analysis reveal that water-soluble photoproducts from biochar produced at 300°C and 900°C are nearly three times as toxic compared to dark controls. The ultrahigh resolving power of 21T FT-ICR MS allows for the separation of tens of thousands of highly oxidized, low-molecular-weight (

Since the start of the twenty-first century, English has come to be seen by the Chinese government as a linchpin of its continued economic and political influence. Its resultant efforts to promote innovation in English language teaching align with the aspirations of a population, many of whom regard competency in English as a determiner of opportunity and success in their careers, and thus a vehicle through which to provide a good quality of life for themselves and their families. However, despite government-driven initiatives to improve English language education, change has been slow to materialize, especially outside of the main urban areas of Eastern China. Here, we report on a study that sought to explore the constraints governing attempts by teachers of English to innovate in universities located in some of the so-called 'hinterland' regions of Southwestern China. Key determinants that emerged, and which we discuss, included time pressure and competing priorities; scepticism towards new ideas; lack of investment in resources; the primacy of the textbook; students' language proficiency; and opportunities for professional development. Together, these findings indicate the need for a change of culture if innovation is to be welcomed, both in principle and in practice, as a driver of positive change in the teaching of English in these universities. Teachers, their line managers, and university senior managers need to feel willing and able to engage freely in constructive and informed discourse, and in doing so consider recalibrating institutional priorities, thereby helping reconcile the pressures and tensions currently experienced by English language teachers and which impede progress.

Abstract The Ice Sheet Model Intercomparison Project for CMIP6 (ISMIP6) is the primary effort of CMIP6 (Coupled Model Intercomparison Project–Phase 6) focusing on ice sheets, designed to provide an ensemble of process‐based projections of the ice‐sheet contribution to sea‐level rise over the twenty‐first century. However, the behavior of the Antarctic Ice Sheet beyond 2100 remains largely unknown: several instability mechanisms can develop on longer time scales, potentially destabilizing large parts of Antarctica. Projections of Antarctic Ice Sheet evolution until 2300 are presented here, using an ensemble of 16 ice‐flow models and forcing from global climate models. Under high‐emission scenarios, the Antarctic sea‐level contribution is limited to less than 30 cm sea‐level equivalent (SLE) by 2100, but increases rapidly thereafter to reach up to 4.4 m SLE by 2300. Simulations including ice‐shelf collapse lead to an additional 1.1 m SLE on average by 2300, and can reach 6.9 m SLE. Widespread retreat is observed on that timescale in most West Antarctic basins, leading to a collapse of large sectors of West Antarctica by 2300 in 30%–40% of the ensemble. While the onset date of retreat varies among ice models, the rate of upstream propagation is highly consistent once retreat begins. Calculations of sea‐level contribution including water density corrections lead to an additional ∼10% sea level and up to 50% for contributions accounting for bedrock uplift in response to ice loading. Overall, these results highlight large sea‐level contributions from Antarctica and suggest that the choice of ice sheet model remains the leading source of uncertainty in multi‐century projections.

Wild bovids provide important ecosystem functions as seed dispersers and vegetation modifiers. Five wild bovids remain in Thailand: gaur (Bos gaurus), banteng (Bos javanicus), wild water buffalo (Bubalus arnee), mainland serow (Capricornis sumatraensis) and Chinese goral (Naemorhedus griseus). Their populations and habitats have declined substantially and become fragmented by land-use change. We use ecological niche models to quantify how much potential suitable habitat for these species remains within protected areas in Asia and then specifically Thailand. We combined species occurrence data from several sources (e.g. mainly camera traps and direct observation) with environmental variables and species-specific and single, large accessible areas in ensemble models to generate suitability maps, using out-of-sample predictions to validate model performance against new independent data. Gaur, banteng and buffalo models showed reasonable model accuracy throughout the entire distribution (greater than or equal to 62%) and in Thailand (greater than or equal to 80%), whereas serow and goral models performed poorly for the entire distribution and in Thailand, though 5 km movement buffers markedly improved the performance for serow. Large suitable areas were identified in Thailand and India for gaur, Cambodia and Thailand for banteng and India for buffalo. Over 50% of suitable habitat is located outside protected areas, highlighting the need for habitat management and conflict mitigation outside protected areas.

Introduction: ALK-positive lung cancers represent a molecularly diverse disease. With drug exposure, driving selection pressure, and resistance pathways, disease relapse will emerge. There is compelling rationale to investigate novel treatment strategies, informed by dynamic circulating tumor DNA (ctDNA) monitoring. Methods: The single-arm, pilot study ALKTERNATE investigated fixed alternating cycles of lorlatinib intercalated with crizotinib in individuals resistant to second-generation ALK inhibitors. Dynamic ctDNA explored the correlation with disease response and disease recurrence and defined disease resistance. The primary outcome was time-to-treatment failure, a composite of tolerability, feasibility, and efficacy. Secondary outcomes included standard survival measures, toxicity, pharmacokinetic analysis, and patient-reported outcomes. Tertiary outcomes were proteogenomic analyses of tissue and plasma. Results: A total of 15 individuals were enrolled; three encountered primary resistance to lorlatinib induction. There were 12 participants who received alternating therapy, and this approach revealed safety, feasibility, and effectiveness. Patient-reported outcomes were maintained or improved on therapy, and toxicity was consistent with previous reports. The pharmacokinetic measures were similar to the single-arm drug experience. Median time-to-treatment failure was 10 months; overall survival was 23 months. ctDNA profiles indicated inferior survival in those with preexistent TP53 mutations and those without clear or cleared ctDNA at trial induction. The study defined a vastly heterogeneous population with an abundance of ALK coexisting with non-ALK resistance variants. Conclusions: ALKTERNATE revealed feasibility with a novel alternating ALK inhibitor strategy in ALK-positive NSCLC. Results support progressing inquiry into this approach and propose a flexible design with drug(s) selected and alternating time frames, informed by real-time plasma profiling. Moving this concept to treatment naive may also optimize impact.

Abstract The rapid increase of publicly available chemical structures and associated experimental data presents a valuable opportunity to build robust QSAR models for applications in different fields. However, the common concern is the quality of both the chemical structure information and associated experimental data. This is especially true when those data are collected from multiple sources as chemical substance mappings can contain many duplicate structures and molecular inconsistencies. Such issues can impact the resulting molecular descriptors and their mappings to experimental data and, subsequently, the quality of the derived models in terms of accuracy, repeatability, and reliability. Herein we describe the development of an automated workflow to standardize chemical structures according to a set of standard rules and generate two and/or three-dimensional “QSAR-ready” forms prior to the calculation of molecular descriptors. The workflow was designed in the KNIME workflow environment and consists of three high-level steps. First, a structure encoding is read, and then the resulting in-memory representation is cross-referenced with any existing identifiers for consistency. Finally, the structure is standardized using a series of operations including desalting, stripping of stereochemistry (for two-dimensional structures), standardization of tautomers and nitro groups, valence correction, neutralization when possible, and then removal of duplicates. This workflow was initially developed to support collaborative modeling QSAR projects to ensure consistency of the results from the different participants. It was then updated and generalized for other modeling applications. This included modification of the “QSAR-ready” workflow to generate “MS-ready structures” to support the generation of substance mappings and searches for software applications related to non-targeted analysis mass spectrometry. Both QSAR and MS-ready workflows are freely available in KNIME, via standalone versions on GitHub, and as docker container resources for the scientific community. Scientific contribution: This work pioneers an automated workflow in KNIME, systematically standardizing chemical structures to ensure their readiness for QSAR modeling and broader scientific applications. By addressing data quality concerns through desalting, stereochemistry stripping, and normalization, it optimizes molecular descriptors' accuracy and reliability. The freely available resources in KNIME, GitHub, and docker containers democratize access, benefiting collaborative research and advancing diverse modeling endeavors in chemistry and mass spectrometry.

Abstract We consider quantum algebras of observables associated with subregions in theories of Einstein gravity coupled to matter in the G N → 0 limit. When the subregion is spatially compact or encompasses an asymptotic boundary, we argue that the algebra is a type II von Neumann factor. To do so in the former case we introduce a model of an observer living in the region; in the latter, the ADM Hamiltonian effectively serves as an observer. In both cases the entropy of states on which this algebra acts is UV finite, and we find that it agrees, up to a state-independent constant, with the generalized entropy. For spatially compact regions the algebra is type II1, implying the existence of an entropy maximizing state, which realizes a version of Jacobson’s entanglement equilibrium hypothesis. The construction relies on the existence of well-motivated but conjectural states whose modular flow is geometric at an instant in time. Our results generalize the recent work of Chandrasekaran, Longo, Penington, and Witten on an algebra of operators for the static patch of de Sitter space.

PurposeTo demonstrate the suitability of optically stimulated luminescence detectors (OSLDs) for accurate simultaneous measurement of the absolute point dose and dose-weighted linear energy transfer (LETD) in an anthropomorphic phantom for experimental validation of daily adaptive proton therapy.MethodsA clinically realistic intensity-modulated proton therapy (IMPT) treatment plan was created based on a CT of an anthropomorphic head-and-neck phantom made of tissue-equivalent material. The IMPT plan was optimized with three fields to deliver a uniform dose to the target volume covering the OSLDs. Different scenarios representing inter-fractional anatomical changes were created by modifying the phantom. An online adaptive proton therapy workflow was used to recover the daily dose distribution and account for the applied geometry changes. To validate the adaptive workflow, measurements were performed by irradiating Al2O3:C OSLDs inside the phantom. In addition to the measurements, retrospective Monte Carlo simulations were performed to compare the absolute dose and dose-averaged LET (LETD) delivered to the OSLDs.ResultsThe online adaptive proton therapy workflow was shown to recover significant degradation in dose conformity resulting from large anatomical and positioning deviations from the reference plan. The Monte Carlo simulations were in close agreement with the OSLD measurements, with an average relative error of 1.4% for doses and 3.2% for LETD. The use of OSLDs for LET determination allowed for a correction for the ionization quenched response.ConclusionThe OSLDs appear to be an excellent detector for simultaneously assessing dose and LET distributions in proton irradiation of an anthropomorphic phantom. The OSLDs can be cut to almost any size and shape, making them ideal for in-phantom measurements to probe the radiation quality and dose in a predefined region of interest. Although we have presented the results obtained in the experimental validation of an adaptive proton therapy workflow, the same approach can be generalized and used for a variety of clinical innovations and workflow developments that require accurate assessment of point dose and/or average LET.

Background and purpose: Respiratory suppression techniques represent an effective motion mitigation strategy for 4D-irradiation of lung tumors with protons. A magnetic resonance imaging (MRI)-based study applied and analyzed methods for this purpose, including enhanced Deep-Inspiration-Breath-Hold (eDIBH). Twenty-one healthy volunteers (41–58 years) underwent thoracic MR scans in four imaging sessions containing two eDIBH-guided MRIs per session to simulate motion-dependent irradiation conditions. The automated MRI segmentation algorithm presented here was critical in determining the lung volumes (LVs) achieved during eDIBH. Materials and methods: The study included 168 MRIs acquired under eDIBH conditions. The lung segmentation algorithm consisted of four analysis steps: (i) image preprocessing, (ii) MRI histogram analysis with thresholding, (iii) automatic segmentation, (iv) 3D-clustering. To validate the algorithm, 46 eDIBH-MRIs were manually contoured. Sørensen-Dice similarity coefficients (DSCs) and relative deviations of LVs were determined as similarity measures. Assessment of intrasessional and intersessional LV variations and their differences provided estimates of statistical and systematic errors. Results: Lung segmentation time for 100 2D-MRI planes was ∼ 10 s. Compared to manual lung contouring, the median DSC was 0.94 with a lower 95 % confidence level (CL) of 0.92. The relative volume deviations yielded a median value of 0.059 and 95 % CLs of −0.013 and 0.13. Artifact-based volume errors, mainly of the trachea, were estimated. Estimated statistical and systematic errors ranged between 6 and 8 %. Conclusions: The presented analytical algorithm is fast, precise, and readily available. The results are comparable to time-consuming, manual segmentations and other automatic segmentation approaches. Post-processing to remove image artifacts is under development.

Background: Per- and polyfluoroalkyl substances (PFAS) encompass a class of chemically and structurally diverse compounds that are extensively used in industry and detected in the environment. The US Environmental Protection Agency (US EPA) 2021 PFAS Strategic Roadmap describes national research plans to address the challenge of PFAS. Objectives: Systematic Evidence Map (SEM) methods were used to survey and summarize available epidemiological and mammalian bioassay evidence that could inform human health hazard identification for a set of 345 PFAS that were identified by the US EPA's Center for Computational Toxicology and Exposure (CCTE) for in vitro toxicity and toxicokinetic assay testing and through interagency discussions on PFAS of interest. This work builds from the 2022 evidence map that collated evidence on a separate set of ~150 PFAS. Like our previous work, this SEM does not include PFAS that are the subject of ongoing or completed assessments at the US EPA. Methods: SEM methods were used to search, screen, and inventory mammalian bioassay and epidemiological literature from peer-reviewed and gray literature sources using manual review and machine-learning software. For each included study, study design details and health end points examined were summarized in interactive web-based literature inventories. Some included studies also underwent study evaluation and detailed extraction of health end point data. All underlying data is publicly available online as interactive visuals with downloadable metadata. Results: More than 13,000 studies were identified from scientific databases. Screening processes identified 121 mammalian bioassay and 111 epidemiological studies that met screening criteria. Epidemiological evidence (available for 12 PFAS) mostly assessed the reproductive, endocrine, developmental, metabolic, cardiovascular, and immune systems. Mammalian bioassay evidence (available for 30 PFAS) commonly assessed effects in the reproductive, whole-body, nervous, and hepatic systems. Overall, 41 PFAS had evidence across mammalian bioassay and epidemiology data streams (roughly 11% of searched chemicals). Discussion: No epidemiological and/or mammalian bioassay evidence were identified for most of the PFAS included in our search. Results from this SEM, our 2022 SEM on ~150 PFAS, and other PFAS assessment products from the US EPA are compiled into a comprehensive PFAS dashboard that provides researchers and regulators an overview of the current PFAS human health landscape including data gaps and can serve as a scoping tool to facilitate prioritization of PFAS-related research and/or risk assessment activities. https://doi.org/10.1289/EHP13423, Introduction There is a growing need to understand the human health effects of per- and polyfluoroalkyl substances (PFAS) because human exposure to these persistent and bioaccumulative compounds is widespread. (1) [...]

Environ Health Perspect. 130(5):056001 (2022), https://doi.org/10.1289/EHP10343 In the originally published article, 6 of the 171 PFAS included in the evidence map were inadvertently omitted in literature search updates for 2020 [...]

Abstract Gravitational subsystems with boundaries carry the action of an infinite-dimensional symmetry algebra, with potentially profound implications for the quantum theory of gravity. We initiate an investigation into the quantization of this corner symmetry algebra for the phase space of gravity localized to a region bounded by a 2-dimensional sphere. Starting with the observation that the algebra sdiff $$ \mathfrak{sdiff} $$ (S 2) of area-preserving diffeomorphisms of the 2-sphere admits a deformation to the finite-dimensional algebra su $$ \mathfrak{su} $$ (N), we derive novel finite-N deformations for two important subalgebras of the gravitational corner symmetry algebra. Specifically, we find that the area-preserving hydrodynamical algebra sdiff S 2 ⊕ L ℝ S 2 $$ \mathfrak{sdiff}\left({S}^2\right){\oplus}_{\mathcal{L}}{\mathbb{R}}^{S^2} $$ arises as the large-N limit of sl N ℂ ⊕ ℝ $$ \mathfrak{sl}\left(N,\mathbb{C}\right)\oplus \mathbb{R} $$ and that the full area-preserving corner symmetry algebra sdiff S 2 ⊕ L sl 2 ℝ S 2 $$ \mathfrak{sdiff}\left({S}^2\right){\oplus}_{\mathcal{L}}\mathfrak{sl}{\left(2,\mathbb{R}\right)}^{S^2} $$ is the large-N limit of the pseudo-unitary group su $$ \mathfrak{su} $$ (N, N). We find matching conditions for the Casimir elements of the deformed and continuum algebras and show how these determine the value of the deformation parameter N as well as the representation of the deformed algebra associated with a quantization of the local gravitational phase space. Additionally, we present a number of novel results related to the various algebras appearing, including a detailed analysis of the asymptotic expansion of the su $$ \mathfrak{su} $$ (N) structure constants, as well as an explicit computation of the full diff $$ \mathfrak{diff} $$ (S 2) structure constants in the spherical harmonic basis. A consequence of our work is the definition of an area operator which is compatible with the deformation of the area-preserving corner symmetry at finite N.

Atlantic salmon is an important aquaculture species that has fascinated naturalists for centuries, resulting in its biology being widely characterized. Certain details about the early development and the inheritance of meristic variation in the post‐cranial axial skeleton are, however, largely unexplored. The present study gives a detailed description of the sequence of formation of the post‐cranial axial skeleton based on whole‐mount staining and used radiology to investigate the inheritance of meristic variation in isogenic hybrid all‐male families of Atlantic salmon (~4 kg). Eight different families were created by crossing two homozygous double haploid XX females (dam A, B) with four different double haploid homozygous YY super males (sires a to d). In the caudal fin complex, the first bone to form is hypural 1 and its associated lepidotrichia followed by a bidirectional formation of new bones. In the dorsal and anal fins, development starts in the cranial part, and new bones form bidirectionally towards the head and tail fin. The neural and haemal arches start to form at segment 43, and further development is bidirectional. The first parapophysis form in the caudal part of the abdomen followed by a unidirectional completion cranially. The first ribs form at segment 3 and new ribs develop unidirectional caudally. Chordacentra formation starts at segment 24 followed by formation of chordacentrum number 58 (caudal‐most vertebra). New chordacentrae form bidirectionally from segment 24 in parallel with the formation of chordacentrum number 57. The first epineuralia form at segment 1 followed by a unidirectional completion caudally until segment 30. The first supraneuralia to develop is number 10 closely followed by number 1, then new supraneurals form bidirectionally from number 10. Analysis of the inheritance on the post‐cranial axial skeletal bones showed a strong maternal effect on total vertebrae centra and tail fin lepidotrichia counts. For these skeletal counts, dam A produced offspring with modes of 58 and 45 respectively, while dam B produced offspring with modes of 59 and 42. The higher number of total vertebrae centra produced by dam B was associated with additional abdominal and/or transitional vertebrae. The completion of formation in different post‐cranial axial skeletal parts are either bi‐ or unidirectional, and the initiation of formation is site specific for each skeletal part with some inter‐part similarities. Further, the present results may suggest that there has been a maternally driven selection for more abdominal vertebrae associated with a higher number of total vertebrae, and more tail fin lepidotrichia associated with a lower number of total vertebrae. These changing meristic counts may impact on important fitness‐related traits, such as fecundity and swimming ability, making the present findings relevant for both ecological and aquaculture sciences. [ABSTRACT FROM AUTHOR]

Objectives To investigate trends in the incidence rate and main indication for revision hip replacement (rHR) over the past 15 years in the UK.Design Repeated national cross-sectional study from 2006 to 2020.Setting/participants rHR procedures were identified from the National Joint Registry for England, Wales, Northern Ireland, the Isle of Man and the States of Guernsey. Population statistics were obtained from the Office for National Statistics.Main outcome measures Crude incidence rates of rHR.Results The incidence rate of rHR doubled from 11 per 100 000 adults in 2006 (95% CI 10.7 to 11.3) to a peak of 22 per 100 000 adults (95% CI 22 to 23) in 2012, before falling to 17 per 100 000 adults in 2019 (95% CI 16 to 17) (24.5% decrease from peak). The incidence rate of rHR reduced by 39% in 2020 compared with 2019 (during the COVID-19 pandemic). The most frequent indications for rHR between 2006 and 2019 were loosening/lysis (27.8%), unexplained pain (15.1%) and dislocation/instability (14.7%). There were incremental increases in the annual number and incidence rates of rHR for fracture, infection, dislocation/instability and a decrease in rHR for aseptic loosening/lysis.Conclusions The incidence rate of rHR doubled from 2006 to 2012, likely due to high early failure rates of metal-on-metal hip replacements. The incidence of rHR then decreased by approximately 25% from 2012 to 2019, followed by a large decrease during the COVID-19 pandemic. The decrease in the number of rHR performed for aseptic loosening/lysis may reflect improved wear and implant longevity. Increased healthcare resource will be required to care for the increasing numbers of patients undergoing rHR for fracture and infection.