Dengue outbreaks prediction in Bangladesh perspective using distinct multilayer perceptron NN and decision tree.

Dengue fever is a disease that has been outbreak worldwide in the last few years. Dengue is a fatal disease; sometimes, it may cause life-threatening complications and even death. Dengue is considered to be one of the critical diseases which is spreading in more than 110 countries. Nearly 45,000 case reports have been found around Bangladesh in the last year. Dengue fever has become a major health hazard in Bangladesh. Hence, early detection would mitigate major casualties of Dengue disease. Distinct studies have been performed concerning Dengue disease; however, no effective study, particularly from Bangladesh's perspective, it seemed that reveals Dengue outbreaks prediction method. In this scenario, this research work aims to analyse the Dengue disease and build an apposite model to predict dengue outbreaks. This paper also aims to find the best technique to early predicts Dengue disease. The real-time data of the patients admitted to different hospitals in Bangladesh is accumulated to achieve the goal of the current research. Then different multilayer perceptron neural networks and a Decision tree are used for Dengue outbreaks prediction. Twenty-five parameters are analysed to find these parameters' infection rates in this work. A comparative study of the developed models' performances is also accomplished to obtain a better Dengue outbreaks prediction model. The results evidence that the Levenberg-Marquardt is the best technique with 97.3% accuracy and 2.7% error in Dengue disease prediction. On the other hand, the Decision tree may have the second choice to assess Dengue disease.

Mitigation of Airborne Contaminant Spread through Simple Interventions in an Occupied Single-Family Home.

Historically, reducing aerosol-based transmission of respired viruses in indoor environments has been of importance for controlling influenza viruses and common-cold rhinoviruses. The present public health emergency associated with SARS-CoV-2 makes this topic critically important. Yet to be tested is the potential effectiveness of simple interventions that create an isolation zone (IZ) for a suspected/confirmed sick or sensitive person requiring quarantine. The intent in existing homes is to find a practical means to mitigate exposure to airborne contaminants. In creating an IZ in an occupied single-family home in the study, four simple strategies were tested. The test configurations were: (1) IZ windows closed with IZ bathroom exhaust ventilation fan off, (2) IZ windows closed with IZ exhaust fan on, (3) IZ window open with IZ exhaust fan off, and (4) IZ window open with IZ exhaust fan on. Incense-generated fine particulate matter (PM2.5) was used as a marker for virus transmission. The measured transfer of PM2.5 from the IZ into the main zone (MZ) of the house enabled us to determine the relative effectiveness of four containment strategies. Collectively, the data from pressure differential (across zones) and PM2.5 measurements suggested that the best containment strategy was achieved through continuously operating the bathroom exhaust fan while keeping the windows closed in the IZ (configuration 2). Interventions using open windows were found to be less reliable, due to variability in wind speed and direction, resulting in an unpredictable and sometimes detrimental pressure differential in the IZ with reference to MZ. Our findings strongly suggest a simple IZ exhaust ventilation strategy has the potential for mitigating the risk from the airborne spread of contaminants, such as SARS-CoV-2.

High mortality following revision hip arthroplasty for periprosthetic femoral fracture.

AIMS: To determine mortality risk after first revision total hip arthroplasty (THA) for periprosthetic femoral fracture (PFF), and to compare this to mortality risk after primary and first revision THA for other common indications. METHODS: The study cohort consisted of THAs recorded in the National Joint Registry between 2003 and 2015, linked to national mortality data. First revision THAs for PFF, infection, dislocation, and aseptic loosening were identified. We used a flexible parametric model to estimate the cumulative incidence function of death at 90 days, one year, and five years following first revision THA and primary THA, in the presence of further revision as a competing risk. Analysis covariates were age, sex, and American Society of Anesthesiologists (ASA) grade. RESULTS: A total of 675,078 primary and 74,223 first revision THAs were included (of which 6,131 were performed for PFF). Following revision for PFF, mortality ranged from 9% at 90 days, 21% at one year, and 60% at five years in the highest risk group (males, ≥ 75 years, ASA ≥ 3) to 0.6%, 1.4%, and 5.5%, respectively, for the lowest risk group (females, < 75 years, ASA ≤ 2). Mortality was greater in all groups following first revision THA for PFF than for primary THA. Compared to mortality risk after first revision THA for infection, dislocation, or aseptic loosening, revision for PFF was associated with higher five-year mortality in all groups except males < 75 years with an ASA ≤ 2. CONCLUSION: Mortality risk after revision THA for PFF is high, reaching 60% at five years in the highest risk patient group. In comparison to other common indications for revision, PFF demonstrated the highest overall risk of mortality at five years. These estimates can be used in the surgical decision-making process and when counselling patients and carers regarding surgical risk. Cite this article: Bone Joint J 2020;102-B(12):1670-1674.

A Localized Scaffold for cGMP Increase Is Required for Apical Dendrite Development.

Studies in cultured neurons have established that axon specification instructs neuronal polarization and is necessary for dendrite development. However, dendrite formation in vivo occurs when axon formation is prevented. The mechanisms promoting dendrite development remain elusive. We find that apical dendrite development is directed by a localized cyclic guanosine monophosphate (cGMP)-synthesizing complex. We show that the scaffolding protein Scribble associates with cGMP-synthesizing enzymes soluble-guanylate-cyclase (sGC) and neuronal nitric oxide synthase (nNOS). The Scribble scaffold is preferentially localized to and mediates cGMP increase in dendrites. These events are regulated by kinesin KifC2. Knockdown of Scribble, sGC-ß1, or KifC2 or disrupting their associations prevents cGMP increase in dendrites and causes severe defects in apical dendrite development. Local cGMP elevation or sGC expression rescues the effects of Scribble knockdown on dendrite development, indicating that Scribble is an upstream regulator of cGMP. During neuronal polarization, dendrite development is directed by the Scribble scaffold that might link extracellular cues to localized cGMP increase.

Rates of knee arthroplasty in anterior cruciate ligament reconstructed patients: a longitudinal cohort study of 111,212 procedures over 20 years.

Background and purpose - Long-term rates of knee arthroplasty in patients with anterior cruciate ligament (ACL) injury who undergo ligament reconstruction (ACLr) are unclear. We determined this risk of arthroplasty through comparison with the general population.Patients and methods - All patients undergoing an ACLr in England, 1997-2017, were identified from national hospital statistics. Patients subsequently undergoing a knee arthroplasty were identified and survival analysis was performed (survival without undergoing knee arthroplasty). A Cox proportional hazards model was used to identify factors associated with knee arthroplasty. Relative risk of knee arthroplasty (total or partial) in comparison with the general population was determined.Results - 111,212 ACLr patients were eligible for analysis (mean age 29; 77% male). Overall, 0.46% (95% confidence interval [CI] 0.40-0.52) ACLr patients underwent knee arthroplasty within 5 years, 0.97% (CI 0.82-1.2) within 10 years, and 1.8% (CI 1.4-2.3) within 15 years. Knee arthroplasty risk was greater in older age groups and women. In comparison with the general population, the relative risk of undergoing arthroplasty at a younger age (at time of arthroplasty) was elevated: at 30-39 years (risk ratio [RR] 20; CI 11-35), 40-49 years (RR 7.5; CI 5.5-10), and 50-59 years (RR 2.5; CI 1.8-3.5), but not 60-69 years (RR 1.7; CI 0.93-3.2).Interpretation - Patients sustaining an ACL injury who undergo ACLr are at elevated risk of subsequent knee arthroplasty in comparison with the general population. Although the absolute rate of arthroplasty is low, the risk of arthroplasty at a younger age is particularly elevated. When the outcome of shared decision-making is ACLr, this data will help inform patients and clinicians about the long-term risk of requiring knee arthroplasty.

ACL and meniscal injuries increase the risk of primary total knee replacement for osteoarthritis: a matched case-control study using the Clinical Practice Research Datalink (CPRD).

OBJECTIVES: The aim of this study was to investigate whether ACL injury (ACLi) or meniscal injury increases the risk of end-stage osteoarthritis (OA) resulting in total knee replacement (TKR). METHODS: A matched case-control study of all TKRs performed in the UK between January 1990 and July 2011 and recorded in the Clinical Practice Research Datalink (CPRD) was undertaken. The CPRD contains longitudinal data on approximately 3.6 million patients. Two controls were selected for each case of TKR, matched on age, sex and general practitioner location as a proxy for socioeconomic status. Individuals with inflammatory arthritis were excluded. The odds of having TKR for individuals with a CPRD-recorded ACLi were compared with those without ACLi using conditional logistic regression, after adjustment for body mass index, previous knee fracture and meniscal injury. The adjusted odds of TKR in individuals with a recorded meniscal injury compared with those without were calculated. RESULTS: After exclusion of individuals with inflammatory arthritis, there were 49 723 in the case group and 104 353 controls. 153 (0.31%) cases had a history of ACLi compared with 41 (0.04%) controls. The adjusted OR of TKR after ACLi was 6.96 (95% CI 4.73 to 10.31). 4217 (8.48%) individuals in the TKR group had a recorded meniscal injury compared with 669 (0.64%) controls. The adjusted OR of TKR after meniscal injury was 15.24 (95% CI 13.88 to 16.69). CONCLUSION: This study demonstrates that ACLi is associated with a sevenfold increased odds of TKR resulting from OA. Meniscal injury is associated with a 15-fold increase odds of TKR for OA.

Surgical Stabilization Improves 30-day Mortality in Patients With Traumatic Flail Chest: A Comparative Case Series at a Major Trauma Center.

OBJECTIVES: To evaluate the outcomes including early mortality after surgical rib fixation using a locking plate system as part of a newly introduced chest trauma pathway. DESIGN: Prospective cohort study with retrospective case-controlled matching with a minimum of 1-year follow-up. SETTING: Regional Level 1 trauma center. PATIENTS/PARTICIPANTS: Consecutive patients undergoing surgical rib fixation were prospectively recruited over a 3-year period (56 patients) and matched to similar patients managed nonoperatively (89 patients) using our local trauma registry. Matching was based on injury severity scores and patient demographics. INTERVENTION: Surgical rib fixation with locking plates. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was 30-day mortality with secondary outcomes of hospital length of stay, intensive care unit length of stay, and patient-reported outcome measures including quality of life (EuroQol-EQ-5D-5L). Official causes of death were obtained from the coroner including postmortem results. RESULTS: There was a significant reduction in 30-day mortality in the fixed patients with 1.8% (1/56) compared to 12.4% (11/89) of the nonfixed patients (P = 0.03). This difference remained significant after further exclusion of other nonsurvivable injuries (P = 0.046). Although hospital length of stay was significantly longer in the fixed group, there was no difference on multivariable analysis. Other secondary outcomes were comparable between the groups with no significant differences in any patient-reported measures. CONCLUSIONS: Mortality was significantly lower in patients who underwent rib stabilization. Quality of life and other patient-reported measures were similar, demonstrating no evidence of detrimental longer-term effects of rib stabilization. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Registration and Outcome-Reporting Bias in Randomized Controlled Trials of Distal Radial Fracture Treatment.

BACKGROUND: The purpose of the present study was to systematically evaluate the completeness of trial registration and the extent of outcome-reporting bias in modern randomized controlled trials (RCTs) relating to the treatment of distal radial fracture. METHODS: With use of 4 databases (PubMed, Cochrane CENTRAL, Embase, and PEDro), this systematic review identified all RCTs of distal radial fracture treatment published from January 1, 2010, to December 31, 2015. We independently determined the registration status of these trials in a public trial registry and compared the characteristics of registered and non-registered trials. We assessed the quality and consistency of primary outcome measure (POM) reporting between the registration data and the final published studies. RESULTS: Ninety studies met the inclusion criteria. Of those, only 28 (31%) were registered, and only 3 (3%) were "appropriately registered" (i.e., prospectively registered and identifying and fully describing the POM). Registered trials had larger sample sizes and were more likely to be multicenter, to report funding sources, and to be published in higher-impact-factor journals. Sixteen (18%) of the 90 registered RCTs named a POM in the registry; 7 (44%) of those 16 registered RCTs stated a different POM, an additional POM, or no POM at all in the final publication than was stated in the registry data. Additionally, 13 (81%) of those 16 registered RCTs had discrepancies in the time point reported for the POM. CONCLUSIONS: In an attempt to address publication and outcome-reporting bias, prospective trial registration in a public registry has been deemed a condition for publication by the International Committee of Medical Journal Editors (ICMJE) since 2005. This study shows poor registration rates as well as inconsistencies in the reporting of POMs of recent trials relating to the treatment of distal radial fracture, one of the most common and most investigated injuries in orthopaedic practice. CLINICAL RELEVANCE: The problems of registration and outcome-reporting bias in RCTs are important to highlight and address, and to find a solution will require the cooperation of researchers, reviewers, and journal editors. Increasing the transparency and consistency of reporting will help to increase the quality of research, which can impact patient care through evidence-based guidelines.

Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial.

BACKGROUND: Following surgical fixation of ankle fractures, the traditional management has included immobilisation for 6 weeks in a below-knee cast. However, this can lead to disuse atrophy of the affected leg and joint stiffness. While early rehabilitation from 2 weeks post surgery is viewed as safe, controversy remains regarding its benefits. We will compare the effectiveness of early motion and directed exercise (EMADE) ankle rehabilitation, against usual care, i.e. 6 weeks' immobilisation in a below-knee cast. METHOD/DESIGN: We have designed a pragmatic randomised controlled trial (p-RCT) to compare the EMADE intervention against usual care. We will recruit 144 independently living adult participants, absent of tissue-healing comorbidities, who have undergone surgical stabilisation of isolated Weber B ankle fractures. The EMADE intervention consists of a non-weight-bearing progressive home exercise programme, complemented with manual therapy and education. Usual care consists of immobilisation in a non-weight-bearing below-knee cast. The intervention period is between week 2 and week 6 post surgery. The primary outcome is the Olerud and Molander Ankle Score (OMAS) patient-reported outcome measure (PROM) at 12 weeks post surgery. Secondary PROMs include the EQ-5D-5 L questionnaire, return to work and return to driving, with objective outcomes including ankle range of motion. Analysis will be on an intention-to-treat basis. An economic evaluation will be included. DISCUSSION: The EMADE intervention is a package of care designed to address the detrimental effects of disuse atrophy and joint stiffness. An advantage of the OMAS is the potential of meta-analysis with other designs. Within the economic evaluation, the cost-utility analysis, may be used by commissioners, while the use of patient-relevant outcomes, such as return to work and driving, will ensure that the study remains pertinent to patients and their families. As it is being conducted in the clinical environment, this p-RCT has high external validity. Accordingly, if significant clinical benefits and cost-effectiveness are demonstrated, EMADE should become a worthwhile treatment option. A larger-scale, multicentre trial may be required to influence national guidelines. TRIAL REGISTRATION: ISRCTN, ID: ISRCTN11212729 . Registered retrospectively on 20 March 2017.

Mining legacy across a wetland landscape: high mercury in Upper Peninsula (Michigan) rivers, lakes, and fish.

A geographic enigma is that present-day atmospheric deposition of mercury in the Upper Peninsula of Michigan is low (48%) and that regional industrial emissions have declined substantially (ca. 81% reduction) relative to downstate. Mercury levels should be declining. However, state (MDEQ) surveys of rivers and lakes revealed elevated total mercury (THg) in Upper Peninsula waters and sediment relative to downstate. Moreover, Western Upper Peninsula (WUP) fish possess higher methyl mercury (MeHg) levels than Northern Lower Peninsula (NLP) fish. A contributing explanation for elevated THg loading is that a century ago the Upper Peninsula was a major industrial region, centered on mining. Many regional ores (silver, copper, zinc, massive sulfides) contain mercury in part per million concentrations. Copper smelters and iron furnace-taconite operations broadcast mercury almost continuously for 140 years, whereas mills discharged tailings and old mine shafts leaked contaminated water. We show that mercury emissions from copper and iron operations were substantial (60-650 kg per year) and dispersed over relatively large areas. Moreover, lake sediments in the vicinity of mining operations have higher THg concentrations. Sediment profiles from the Keweenaw Waterway show that THg accumulation increased 50- to 400-fold above modern-day atmospheric deposition levels during active mining and smelting operations, with lingering MeHg effects. High MeHg concentrations are geographically correlated with low pH and dissolved organic carbon (DOC), a consequence of biogeochemical cycling in wetlands, characteristic of the Upper Peninsula. DOC can mobilize metals and elevate MeHg concentrations. We argue that mercury loading from mining is historically superimposed upon strong regional wetland effects, producing a combined elevation of both THg and MeHg in the Western Upper Peninsula.

The impact of patient-specific instrumentation on unicompartmental knee arthroplasty: a prospective randomised controlled study.

PURPOSE: Patient-specific instrumentation (PSI) has been proposed as a means of improving surgical accuracy and ease of implantation during technically challenging procedures such as unicompartmental knee arthroplasty (UKA). The purpose of this prospective randomised controlled trial was to compare the accuracy of implantation and functional outcome of mobile-bearing medial UKAs implanted with and without PSI by experienced UKA surgeons. METHODS: Mobile-bearing medial UKAs were implanted in 43 patients using either PSI guides or conventional instrumentation. Intra-operative measurements, meniscal bearing size implanted, and post-operative radiographic analyses were performed to assess component positioning. Functional outcome was determined using the Oxford Knee Score (OKS). RESULTS: PSI guides could not be used in three cases due to concerns regarding accuracy and registration onto native anatomy, particularly on the tibial side. In general, similar component alignment and positioning was achieved using the two systems (n.s. for coronal/sagittal alignment and tibial coverage). The PSI group had greater tibial slope (p = 0.029). The control group had a higher number of optimum size meniscal bearing inserted (95 vs 52%; p = 0.001). There were no differences in OKS improvements (n.s). CONCLUSION: Component positioning for the two groups was similar for the femur but less accurate on the tibial side using PSI, often with some unnecessarily deep resections of the tibial plateau. Although PSI was comparable to conventional instrumentation based on OKS improvements at 12 months, we continue to use conventional instrumentation for UKA at our institution until further improvements to the PSI guides can be demonstrated. LEVEL OF EVIDENCE: Therapeutic, Level I.

Ectopic Salivary Gland Cyst in the Neck: Association with Congenital Plunging Ranula.

Congenital ranula is rare. We report a large, symptomatic, congenital plunging ranula associated with a salivary gland cyst in the neck. To the best of our knowledge, this is the first such reported case. Even though both the cysts had their origin from the sublingual gland, only the cervical cyst had a capsular covering. Herniation of a part of the immature sublingual gland anlage through a congenital mylohyoid defect, its separation, and subsequent maturation could explain this occurrence.

Fracture liaison services: improving outcomes for patients with osteoporosis.

Fragility fractures are sentinels of osteoporosis, and as such all patients with low-trauma fractures should be considered for further investigation for osteoporosis and, if confirmed, started on osteoporosis medication. Fracture liaison services (FLSs) with varying models of care are in place to take responsibility for this investigative and treatment process. This review aims to describe outcomes for patients with osteoporotic fragility fractures as part of FLSs. The most intensive service that includes identification, assessment and treatment of patients appears to deliver the best outcomes. This FLS model is associated with reduction in re-fracture risk (hazard ratio [HR] 0.18-0.67 over 2-4 years), reduced mortality (HR 0.65 over 2 years), increased assessment of bone mineral density (relative risk [RR] 2-3), increased treatment initiation (RR 1.5-4.25) and adherence to treatment (65%-88% at 1 year) and is cost-effective. In response to this evidence, key organizations and stakeholders have published guidance and framework to ensure that best practice in FLSs is delivered.

Micellar nanocomplexes for biomagnetic delivery of intracellular proteins to dictate axon formation during neuronal development.

During mammalian embryonic development, neurons polarize to create distinct cellular compartments of axon and dendrite that inherently differ in form and function, providing the foundation for directional signaling in the nervous system. Polarization results from spatio-temporal segregation of specific proteins' activities to discrete regions of the neuron to dictate axonal vs. dendritic fate. We aim to manipulate axon formation by directed subcellular localization of crucial intracellular protein function. Here we report critical steps toward the development of a nanotechnology for localized subcellular introduction and retention of an intracellular kinase, LKB1, crucial regulator of axon formation. This nanotechnology will spatially manipulate LKB1-linked biomagnetic nanocomplexes (LKB1-NCs) in developing rodent neurons in culture and in vivo. We created a supramolecular assembly for LKB1 rapid neuronal uptake and prolonged cytoplasmic stability. LKB1-NCs retained kinase activity and phosphorylated downstream targets. NCs were successfully delivered to cultured embryonic hippocampal neurons, and were stable in the cytoplasm for 2 days, sufficient time for axon formation. Importantly, LKB1-NCs promoted axon formation in these neurons, representing unique proof of concept for the sufficiency of intracellular protein function in dictating a central developmental event. Lastly, we established NC delivery into cortical progenitors in live rat embryonic brain in utero. Our nanotechnology provides a viable platform for spatial manipulation of intracellular protein-activity, to dictate central events during neuronal development.

Migration of Ventriculoperitoneal Shunt into a Hernia Sac: An Unusual Complication of Ventriculoperitoneal Shunt Surgery in Children.

We report 2 cases of ventriculoperitoneal (VP) shunt migration into an inguinal hernia sac. In both cases hernia manifested itself on the right side in late infancy. We attempted to analyse the anatomical and mechanical factors leading to shunt migration as seen in the X-rays of our cases.

Geographic variation in medication adherence in commercial and Medicare part D populations.

BACKGROUND: Previous literature has emphasized the importance of cost sharing, health literacy, socioeconomic status, cognitive function, disease burden, and polypharmacy as some of the determinants of medication adherence. Little research has been published examining disparities in adherence rates when comparing different regions of the United States. OBJECTIVE: To examine the impact of geography, socioeconomic status, and other demographic variables on medication adherence rates in a large national sample of Medicare Part D and commercially insured beneficiaries. METHODS: This study focused on users of oral antidiabetic, antihypertensive, and/or antilipidemic medications. Beneficiaries who had at least 2 antidiabetic, antihypertensive, or antilipidemic prescription fills in 2010, 2011, or 2012 and who were enrolled in a large commercial or Medicare Part D prescription drug plan for at least 80% of one of these years (9.6 months) were included in this study. Results were stratified by year and by benefit type. Logistic regression was used to test for the adherence differences among the 9 U.S. regions as defined by the U.S. Census Bureau. Additional variables included in the model to control for population differences were age, gender, socioeconomic status, and yearly out-of-pocket medication expenses. RESULTS: After meeting all inclusion and exclusion criteria, 379,533 beneficiaries were in the 2012 Medicare cohort, and 659,553 beneficiaries were in the 2012 commercial cohort. New England was statistically the most adherent geographic region in both cohorts (Medicare odds ratio [OR] = 1.512, CI = 1.399-1.635); commercial OR = 1.193, CI = 1.109-1.284). Younger age beneficiaries, lower income beneficiaries, and females were less adherent in both groups. CONCLUSIONS: In the commercial and Medicare populations, geography, socioeconomic status, age, and gender all impact the likelihood of a beneficiary being adherent to chronic medications for hypertension, diabetes, and hyperlipidemia. While this study does not elucidate the specific factors (i.e., health literacy, disease severity) driving geographic and other differences in medication adherence observed between groups, it does highlight the limitations of quality metrics and wellness initiatives that assume relative homogeneity in beneficiary characteristics across the United States.

Herlyn-Weber-Wunderlich syndrome with ectopic ureter in prepubertal female.

We report a rare case of uterovaginal duplication in a prepubertal female. The patient also had a permeable ureter (ureter with urine passing through it) subtending a poorly functioning kidney with ectopic insertion in the obstructed hemivagina.

Validating a global rating scale to monitor individual resident learning curves during arthroscopic knee meniscal repair.

PURPOSE: To determine whether a global rating scale (GRS) with construct validity can also be used to assess the learning curve of individual orthopaedic trainees during simulated arthroscopic knee meniscal repair. METHODS: An established arthroscopic GRS was used to evaluate the technical skill of 19 orthopaedic residents performing a standardized arthroscopic meniscal repair in a bioskills laboratory. The residents had diagnostic knee arthroscopy experience but no experience with arthroscopic meniscal repair. Residents were videotaped performing an arthroscopic meniscal repair on 12 separate occasions. Their performance was assessed by use of the GRS and motion analysis objectively measuring the time taken to complete tasks, path length of the subject's hands, and number of hand movements. One author assessed all 228 videos, whereas 2 other authors rated 34 randomly selected videos, testing the interobserver reliability of the GRS. The validity of the GRS was tested against the motion analysis. RESULTS: Objective assessment with motion analysis defined the surgeon's learning curve, showing significant improvement by each subject over 12 episodes (P < .0001). The GRS also showed a similar learning curve with significant improvements in performance (P < .0001). The median GRS score improved from 15 of 34 (interquartile range, 14 to 17) at baseline to 22 of 34 (interquartile range, 19 to 23) in the final period. There was a moderate correlation (P < .0001, Spearman test) between the GRS and motion analysis parameters (r = -0.58 for time, r = -0.58 for path length, and r = -0.51 for hand movements). The inter-rater reliability among 3 trained assessors using the GRS was excellent (Cronbach α = 0.88). CONCLUSIONS: When compared with motion analysis, an established arthroscopic GRS, with construct validity, also offers a moderately feasible method to monitor the learning curve of individual residents during simulated knee meniscal repair. CLINICAL RELEVANCE: An arthroscopic GRS can be used for monitoring skill improvement during knee meniscal repair and has the potential for use as a training and assessment tool in the real operating room.

Managing specialty medication services through a specialty pharmacy program: the case of oral renal transplant immunosuppressant medications.

BACKGROUND: Immunosuppressive medication therapy after organ transplantation is essential for preventing transplant rejection and minimizing the need for re-transplantations. Nonadherence to immunosuppressant therapy has been identified as a major risk factor for acute complications and allograft rejection, as well as late graft rejection, and a return to dialysis after failed renal transplantation, leading to an increase in health care costs and potentially even death. OBJECTIVE: To evaluate clinical and economic outcomes of a mandatory transplant specialty pharmacy program implemented for the membership of a national commercial health plan for post-renal transplantation patients, as compared with membership using traditional retail pharmacy services. This program was delivered by a designated specialty pharmacy, which met requirements for contracted rates and provision of clinical programs and services. METHODS: The study is a 1-year retrospective claims analysis after the implementation of a transplant specialty pharmacy program that, in addition to medication dispensing, includes adherence and clinical management programs, patient education, and counseling services provided by transplant pharmacology experts. Renal transplant patients using the specialty pharmacy program were matched to those using retail pharmacies utilizing a propensity score-matching technique based on logistic regression. Primary outcomes were financial, which included pharmacy medication costs, medical inpatient and outpatient costs, and overall health care costs. Patient adherence to transplant medication therapy and health care resource utilization were also evaluated. One-year outcomes post-specialty pharmacy program implementation were compared between the two groups with t-tests for continuous variables and chi-square tests for nominal variables. RESULTS: After propensity score matching, 519 patients were identified per group for analysis. Baseline parameters were similar between the two groups. The mean total health care cost during 1 year of follow-up was 15% lower in the specialty pharmacy program group ($24,315 vs. $27,891, P = 0.03). Similarly, the mean transplant-related medical cost was 42% lower in the specialty pharmacy program group ($5,960 vs. $8,486; P = 0.04), with lower cost, although not statistically significant, in both the dialysis-related and the nondialysis-related costs. The transplant-related office visit costs ($395 vs. $555; P = 0.04) were significantly lower for the specialty pharmacy program cohort, while the inpatient and outpatient transplant-related costs were lower but not statistically significant in the specialty program. The weighted medication procession ratio (MPR) was higher (0.87 vs. 0.83; P less than 0.0001); the number of patients with a medication gap or who discontinued was lower (65 vs. 142; P less than 0.0001) in the specialty pharmacy program members than in the retail pharmacy members. CONCLUSIONS: This specialty pharmacy program is associated with lower transplant-related medical costs and lower overall health care costs, as well as higher transplant medication adherence within the first year of evaluation. The positive impact of health plan program design and coordinated care and oversight by transplant pharmacology experts in a specialty pharmacy program has implications for the current health care reform and requires more research.