Search

The article discusses a study conducted to estimate the societal economic burden related to work-related All-Terrain Vehicle (ATV) fatalities among civilians more than 17 years of age in the U.S. from 2003 through 2006. It has been informed that the data of ATV death were obtained from the Bureau of Labor Statistics' annual Census of Fatal Occupational Injuries and it was found that short-term investment in prevention measures could prevent work-related ATV deaths.

The article focuses on the efficacy of a video-based safety training intervention (VBSTI) to reduce injuries among loggers from 1999-2007 in West Virginia. The study gathered information from WV Workers' Compensation data on assessing the trend in injury rates, medical and damage costs caused by logging injuries. Statistical findings show that there is a significant decrease on head and neck injuries, medical and damage costs, a significant increase on fall, while no changes in struck-by-object accidents. Hence, the study concludes that no defined assessment of the decreasing claims is attributed by the VBSTI.

The purposes of this study were (1) to determine whether a university student health center (SHC) is a feasible location to introduce a campus-based screening and brief intervention (SBI) program for alcohol and (2) to determine whether the patients seen in the SHC differ in terms of the prevalence and severity of alcohol-related problems compared with students reported by emergency department programs. The authors used motivational interview techniques to counsel subjects from a convenience sample of patients waiting for medical treatment in the SHC who had screened positive with the Alcohol Use Disorders Identification Test (AUDIT). The authors interviewed patients again after 3 months. Seventy-five percent of eligible students participated. Sixty percent screened positive and received an intervention. The authors contacted 66 students (51.2%) again after 3 months. Seventy-five percent of students interviewed again after 3 months reported that SBI was helpful, 92% found the information clear, and 90% thought that the SHC was a good place to learn this information. [ABSTRACT FROM AUTHOR]

PD-1 immune checkpoint blockade occasionally results in durable clinical responses in advanced metastatic cancers. However, mechanism-based predictors of response to this immunotherapy remain incompletely characterized. We performed comprehensive genomic profiling on a tumor and germline sample from a patient with refractory lung adenocarcinoma who achieved marked long-term clinical benefit from anti-PD-L1 therapy. We discovered activating somatic and germline amino acid variants in JAK3 that promoted PD-L1 induction in lung cancer cells and in the tumor immune microenvironment. These findings suggest that genomic alterations that deregulate cytokine receptor signal transduction could contribute to PD-L1 activation and engagement of the PD-1 immune checkpoint in lung cancer.

Background: Reverse shoulder arthroplasty (RSA) is a widely performed surgical procedure to address various shoulder pathologies. Several studies have suggested that radiographic soft-tissue thickness may play a role in predicting complications after orthopedic surgery, but there have been limited studies determining the use of radiographic soft-tissue thickness in RSA. The purpose of this study was to evaluate whether radiographic soft-tissue thickness could predict clinical outcomes after RSA and compare the predictive capabilities against body mass index (BMI). We hypothesized that increased radiographic shoulder soft-tissue thickness would be a strong predictor of operative time, length of stay (LOS), and infection in elective RSA., Material and Methods: A retrospective review of patients undergoing RSA at an academic institution was conducted. Preoperative radiographic images were evaluated including measurements of the radius from the humeral head center to the skin (HS), deltoid radius-to-humeral head radius ratio (DHR), deltoid size, and subcutaneous tissue size. Different correlation coefficients were used to analyze various types of relationships, and the strength of these associations was classified based on predefined boundaries. Subsequently, multivariable linear and logistic regressions were performed to determine whether HS, DHR, deltoid size, and subcutaneous tissue size could predict LOS, operative time, or infection while controlling for patient factors., Results: HS was the most influential factor in predicting both operative time and LOS after RSA, with strong associations indicated by standardized β coefficients of 0.234 for operative time and 0.432 for LOS. Subcutaneous tissue size, deltoid size, and DHR also showed stronger predictive values than BMI for both outcomes. In terms of prosthetic joint infection, HS, deltoid size, and DHR were significant predictors, with HS demonstrating the highest predictive power (Nagelkerke R 2 = 0.44), whereas BMI did not show a statistically significant association with infection. Low event counts resulted in wide confidence intervals for odds ratios in the infection analysis., Conclusion: Greater shoulder soft-tissue thickness as measured with concentric circles on radiographs is a strong predictor of operative time, LOS, and postoperative infection in elective primary RSA patients., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to evaluate associations between demographics and Coronal Plane Alignment of the Knee (CPAK) classification in pre-surgical TKA patients. Methods: This is a retrospective study of 1167 patients with knee osteoarthritis who underwent TKA. CPAK categories I-IX were determined by arithmetic mechanical hip-knee-ankle angle and joint line obliquity measurements from pre-operative bone length radiographs. Patient age, sex, body mass index (BMI) and race were collected. Chi-square test of independence and adjusted Pearson's residuals evaluated associations between CPAK classification and demographics. Results: There was a significant association between CPAK phenotypes I-IX and patient sex (X 2 = 5.8, p < 0.01). A positive association was found between both men and CPAK phenotype I, and women and CPAK phenotype VII. A positive association was found between African American patients and CPAK phenotype III and a negative association was found between African American patients and CPAK phenotype I (X 2 =14.8, p -value = 0.01). There was no association between age and BMI with CPAK phenotypes (n.s.). Conclusion: These results indicate that there are unidentified sex and race differences that exist in the CPAK classification of native arthritic knees. Patient characteristics play a significant role in determining patient knee phenotypes. Further research should investigate whether these characteristics warrant inclusion in pre-operative preparations, aiming to enhance the personalization of arthroplasty procedures., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Several randomized controlled trials (RCTs) have been conducted to assess the use of tranexamic acid (TXA) in the setting of arthroscopic rotator cuff repair (ARCR). However, these studies have shown mixed results, with some showing improved intraoperative visualization, subsequent operative times, and pain levels, and others finding no difference., Purpose: To perform a systematic review of the RCTs in the literature to evaluate the use of TXA on ARCR., Study Design: Meta-analysis; Level of evidence, 1., Methods: Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing TXA with a control in ARCR were included. Visualization, postoperative pain, operative time, pump pressures, and shoulder swelling were evaluated. A P value < .05 was deemed statistically significant., Results: Six RCTs with 450 patients were included in this review. Overall, 5 studies evaluated intraoperative visualization, with 3 studies finding a significant difference in favor of TXA. With TXA, patients had a lower mean postoperative visual analog scale (VAS) score of 3.3, and with the control, patients had a mean VAS score of 4.1, which was statistically significant ( P = .001). With TXA, the mean weighted operation time was 79.3 minutes, and with the control, the mean operation time was 88.8 minutes, which was statistically significant ( P = .001). No study found any difference in intraoperative pump pressures or swelling., Conclusion: TXA improved visualization, operative time, and subsequent postoperative pain levels in patients undergoing ARCR., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.L. has received support for education from TriCoast Surgical Solutions and SouthTech Orthopedics. O.A. has received consulting fees from Exactech Inc, Smith & Nephew, Medical Device Business Services, Biomentus, Lima USA, Responsive Arthroscopy, Encore Medical, and Stryker; support for education from Arthrex and SouthTech Orthopedics; and travel expenses from Wright Medical Technology and Zimmer Biomet Holdings. M.J.A. has received consulting fees from BodyCad, JRF Ortho, and Mitek; research support from Orcosa Inc; support for education from Suvon Surgical, Arthrex, and Gotham Surgical Solutions & Devices; and publishing royalties from Springer. C.K. has received consulting fees from Acumed, restore3d, and Smith & Nephew and holds stock or stock options in GE Healthcare, Johnson & Johnson, Merck, and Pfizer. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Purpose: Interfragmentary strain influences whether a fracture will undergo direct and indirect fracture healing. Orthopedic trauma surgeons modulate strain and create optimal biomechanical environments for specific fracture patterns using fixation constructs. However, objective intraoperative interfragmentary strain measurement does not currently inform fixation strategy in common practice. This review identifies potential methods and technologies to enable intraoperative strain measurement for guiding optimal fracture fixation strategies., Methods: PubMed, Scopus, and Web of Science were methodologically queried for manuscripts containing terms related to "bone fracture," "strain," "measurement," and "intraoperative." Manuscripts were systematically screened for relevance and adjudicated by three reviewers. Relevant articles describing methods to measure interfragmentary strain intraoperatively were summarized., Results: After removing duplicates, 1404 records were screened initially. There were 49 manuscripts meeting criteria for in-depth review. Of these, four reports were included in this study that described methods applicable to measuring interfragmentary strain intraoperatively. Two of these reports described a method using instrumented staples, one described optical tracking of Kirschner wires, and one described using a digital linear variable displacement transducer with a custom external fixator., Conclusion: The four reports identified by this review describe potential methods to quantify interfragmentary strain after fixation. However, further studies are needed to confirm the precision and accuracy of these measurements across a range of fractures and fixation methods. Additionally, described methods require the insertion and likely removal of additional implants into the bone. Ideally, innovations that measure interfragmentary strain intraoperatively would provide dynamic biomechanical feedback for the surgeon to proactively modulate construct stability., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Case: A 16-year-old male patient presented with isolated bilateral sacroiliac (SI) joint dislocation. In this report, we discuss the presentation and focus on strategies for operative reduction and fixation for this rare injury., Conclusion: In conclusion, we present a case of a bilateral ligamentous SI joint dislocation in an adolescent. The patient was reduced in the supine position with a sacral bump and bilateral traction with direct and indirect reduction aids inserted through a lateral window. Bilateral SI screws stabilized the pelvis, facilitating uncomplicated healing., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C221)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Although there is increased utilization of stemless humeral implants in anatomic total shoulder arthroplasty (TSA), there are inadequate objective metrics to evaluate bone quality sufficient for fixation. Our goals are to: (1) compare patient characteristics in patients who had plans for stemless TSA but received stemmed TSA due to intraoperative assessments and (2) propose threshold values of bone density, using the deltoid tuberosity index (DTI) and proximal humerus Hounsfield units (HU), on preoperative X-ray and computed tomography (CT) to allow for preoperative determination of adequate bone stock for stemless TSA., Methods: This is an observational study conducted at an academic institution from 2019 to 2021, including consecutive primary TSAs templated to undergo stemless TSA based on 3-dimensional CT preoperative plans. Final implant selection was determined by intraoperative assessment of bone quality. Preoperative X-ray and CT images were assessed to obtain DTI and proximal humeral bone density in HU, respectively. A receiver operating characteristic curve was used to analyze the potential of preoperative X-ray and CT to classify patients as candidates for stemless TSA., Results: A total of 61 planned stemless TSAs were included, with 56 (91.8%) undergoing stemless TSA and 5 (8.2%) undergoing stemmed TSA after intraoperative assessment determined that the bone quality was inadequate for stemless fixation. There were no significant differences between the 2 groups in terms of gender (P = .640), body mass index (P = .296), and race (P = .580). The stem cohort was significantly older (mean age 69 ± 12 years vs. 59 ± 10 years, P = .029), had significantly lower DTI (1.45 ± 0.13 vs. 1.68 ± 0.18, P = .007), and had significantly less proximal humeral HU (-1.4 ± 17.7 vs. 78.8 ± 52.4, P = .001). The receiver operating characteristic curve for DTI had an area under the curve (AUC) of 0.86, and bone density in HU had an AUC of 0.98 in its ability to distinguish patients who underwent stemless TSA vs. short-stem TSA. A threshold cutoff of 1.41 for DTI resulted in a sensitivity of 98% and a specificity of 60%, and a cutoff value of 14.4 HU resulted in a sensitivity of 95% and a specificity of 100%., Conclusions: Older age, lower DTI, and less proximal humeral bone density in HU were associated with the requirement to switch from stemless to short-stem humeral fixation in primary TSA. Preoperative DTI had good ability (AUC of 0.86) and preoperative HU had excellent ability (AUC of 0.98) to categorize patients as appropriate for stemless TSA. This can help surgeons adequately plan humeral fixation using standard preoperative imaging data., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objective: Surgical instrument oversupply drives cost, confusion, and workload in the operating room. With an estimated 78%-87% of instruments being unused, many health systems have recognized the need for supply refinement. By manually recording instrument use and tasking surgeons to review instrument trays, previous quality improvement initiatives have achieved an average 52% reduction in supply. While demonstrating the degree of instrument oversupply, previous methods for identifying required instruments are qualitative, expensive, lack scalability and sustainability, and are prone to human error. In this work, we aim to develop and evaluate an automated system for measuring surgical instrument use., Materials and Methods: We present the first system to our knowledge that automates the collection of real-time instrument use data with radio-frequency identification (RFID). Over 15 breast surgeries, 10 carpometacarpal (CMC) arthroplasties, and 4 craniotomies, instrument use was tracked by both a trained observer manually recording instrument use and the RFID system., Results: The average Cohen's Kappa agreement between the system and the observer was 0.81 (near perfect agreement), and the system enabled a supply reduction of 50.8% in breast and orthopedic surgery. Over 10 monitored breast surgeries and 1 CMC arthroplasty with reduced trays, no eliminated instruments were requested, and both trays continue to be used as the supplied standard. Setup time in breast surgery decreased from 23 min to 17 min with the reduced supply., Conclusion: The RFID system presented herein achieves a novel data stream that enables accurate instrument supply optimization., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Background: Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous., Methods: Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests., Results: The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P  = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%., Conclusions: Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications., (© 2020 Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons.)

Background: Significant analysis errors can be caused by nonvalidated data quality of electronic health records data. To determine surgical data fitness, a framework of foundational and study-specific data analyses was adapted and assessed using conformance, completeness, and plausibility analyses., Study Design: Electronic health records-derived data from a cohort of 241,695 patients undergoing 412,182 procedures from October 1, 2014 to August 31, 2018 at 3 hospital sites was evaluated. Data quality analyses tested CPT codes, medication administrations, vital signs, provider notes, labs, orders, diagnosis codes, medication lists, and encounters., Results: Foundational checks showed that all encounters had procedures within the inclusion period, all admission dates occurred before discharge dates, and race was missing for 1% of patients. All procedures had associated CPT codes, 69% had recorded blood pressure, pulse, temperature, respiration rate, and oxygen saturation. After curation, all medication matched RxNorm medication naming standards, 84% of procedures had current outpatient medication lists, and 15% of procedures had missing procedure notes. Study-specific checks temporally validated CPT codes, intraoperative medication doses were in conventional units, and of the 13,500 patients who received blood pressure medication intraoperatively, 93% had a systolic blood pressure >140 mmHg. All procedure notes were completed within less than 30 days of the procedure and 93% of patients after total knee arthroplasty had postoperative physical therapy notes. All patients with postoperative troponin-T lab values ≥0.10 ng/mL had more than 1 ECG with relevant diagnoses. Postoperative opioid prescription decreased by 8.8% and nonopioid use increased by 8.8%., Conclusions: High levels of conformance, completeness, and clinical plausability demonstrate higher quality of real-world data fitness and low levels demonstrate less-fit-for-use data., (Copyright © 2020. Published by Elsevier Inc.)

Introduction: Extremity lipomas and well-differentiated liposarcomas (WDLs) are difficult to distinguish on MR imaging. We sought to evaluate the accuracy of MRI interpretation using MDM2 amplification, via fluorescence in-situ hybridization (FISH), as the gold standard for pathologic diagnosis. Furthermore, we aimed to investigate the utility of a diagnostic formula proposed in the literature., Methods: We retrospectively collected 49 patients with lipomas or WDLs utilizing MDM2 for pathologic diagnosis. Four expert readers interpreted each patient's MRI independently and provided a diagnosis. Additionally, a formula based on imaging characteristics (i.e. tumor depth, diameter, presence of septa, and internal cystic change) was used to predict the pathologic diagnosis. The accuracy and reliability of imaging-based diagnoses were then analyzed in comparison to the MDM2 pathologic diagnoses., Results: The accuracy of MRI readers was 73.5% (95% CI 61-86%) with substantial interobserver agreement ( κ =0.7022). The formula had an accuracy of 71%, which was not significantly different from the readers ( p =0.71). The formula and expert observers had similar sensitivity (83% versus 83%) and specificity (64.5% versus 67.7%; p =0.659) for detecting WDLs., Conclusion: The accuracy of both our readers and the formula suggests that MRI remains unreliable for distinguishing between lipoma and WDLs.

Wildland fire fighting is a high-risk occupation requiring considerable physical and psychological demands. Multiple agencies publish fatality summaries for wildland firefighters; however, the reported number and types vary. At least five different surveillance systems capture deaths, each with varying case definitions and case inclusion/exclusion criteria. Four are population-level systems and one is case-based. System differences create challenges to accurately characterize fatalities. Data within each of the five surveillance systems were examined to better understand the types of wildland firefighter data collected, to assess each system's utility in characterizing wildland firefighter fatalities, and to determine each system's potential to inform prevention strategies. To describe similarities and differences in how data were recorded and characterized, wildland fire deaths for three of the population-based systems were matched and individual fatalities across systems were compared. Between 2001 and 2012, 247 unique deaths were captured among the systems; 73% of these were captured in all three systems. Most common causes of death in all systems were associated with aviation, vehicles, medical events, and entrapments/burnovers. The data show that, although the three systems often report similar annual summary statistics, events captured in each system vary each year depending on the types of events that the system is designed to track, such as inclusion/exclusion of fatalities associated with the Hometown Heroes Survivor Benefits Act of 2003. The overarching and central goal of each system is to collect accurate and timely information to improve wildland firefighter safety and health. Each system is unique and has varying inclusion and exclusion criteria for capturing and tracking different subsets of wildland firefighter tasks and duties. Use of a common case definition and better descriptions and interpretations of the data and the results would help to more accurately characterize wildland firefighter traumatic injuries and illnesses, lessen the likelihood for misinterpretation of wildland firefighter fatality data, and assist with defining the true occupational injury burden within this high-risk population.

The objective of this study was to summarize basic information on the characteristics of work-related A TV deaths among civilian persons 18 years of age or older in the U.S. from 1992 through 2007. Work-related ATV death data were obtained through the Bureau of Labor Statistics' annual Census of Fatal Occupational Injuries. From 1992 to 2007, 297 work-related ATV deaths occurred among persons over 17 in the U.S. Ninety-two percent were male, 93% were white, 23% were ages 18 to 34, 51% were ages 35 to 64, and 26% were ages > or = 65. Half of the fatal incidents involved overturns resulting in head and chest injuries. Sixty percent of crashes occurred on farms and 20% occurred on highways. The fatality rate among agricultural production workers was significantly higher than the rates in all other industries. While more in-depth analysis of incident and exposure data for this growing problem will more clearly define personal risk and causal factors in the long term, in the short term, stronger emphasis must be placed on the development of prevention strategies, particularly focused on older workers in the agriculture production industry.

During the 9-year period from 2000-2008, West Virginia experienced 301 deaths related to All-terrain Vehicles (ATVs). The distribution of ATV deaths across the top 20 counties in West Virginia accounted for nearly seventy percent of the ATV-related deaths during the 9-year study period. Time-of-day was a significant predictor of population-based rates, and a 34% decrease in the fatality rate from 2.94 in 2006 to 1.93 in 2008 occurred. We opine that the decline in ATV mortality is possibly due to better enforcement of the (WV Code Chapter 17F), mandatory ATV regulations passed by the West Virginia State Legislature in 2004. Improved safety vigilance and ATV operator adherence to manufacturers' safety guidelines may have also contributed to the decreasing incidence of ATV deaths. While the current downward trend is most welcome, more attention should be directed towards high-risk behaviors including alcohol and drug abuse and driving on paved surfaces.

Objectives: The purpose of this paper was to explore how events that counselors endorsed occurring during an emergency department-based screening and brief intervention (SBI) for drinking discriminate patients who reported change in Alcohol Use Disorder Identification Test (AUDIT) domains at follow-up from those who did not., Method: Patients who scored ">5" on the AUDIT were eligible for SBI. At the end of each intervention, counselors completed the questionnaire indicating which parts of the intervention they just used., Results: Discriminant function analyses indicated that "Referral made" discriminated for alcohol intake change (Wilks' lambda = 0.993, P < .05); "Did the patient set goals during intervention?" and "Referral made" discriminated for alcohol dependency change (Wilks' lambda = 0.940 and Wilks' lambda = 0.919, P < .05, respectively). "Intention to quit" (Wilks' lambda = 0.984, P < .05) discriminated for alcohol-related harm change., Conclusions: Making referrals to addiction treatment during motivational intervention discriminated for alcohol intake and dependency change. Working on intention to quit is an important point in changing alcohol-related harm. When conducting the SBI in ED, counselors may be mindful in making appropriate referrals to address alcohol use and examine intention to quit to maximize the efficacy of the harm-reduction approach.

Background and Objective: Injuries are a leading cause of death, significant disability, and utilization of acute medical care. This study describes patterns of acute care services use related to injury and associated costs among children and adolescents in a state Medicaid population., Methods: A retrospective, cross-sectional, descriptive research design was used to analyze 2003 West Virginia Medicaid fee-for-service computerized claims for acute care medical services with a primary diagnosis of injury or complication due to injury for recipients below 21 years of age. Medical services utilization rates were calculated and stratified by demographic categories as well as by type of injury. Costs associated with the claims were from the perspective of Medicaid., Results: There were 33,599 children who were hospitalized or visited the emergency department for injury or complication due to injury at a rate of 227.2 per 1,000. Children who were white, male, and 15-20 years of age had the highest rate of acute care use by demographic groups. Medicaid paid approximately $7.4 million for injury-related acute care visits. Acute care was mostly delivered in the emergency department, although hospitalizations contributed to one-third of the total costs. The average length of hospital stay for any type of injury or complication due to injury was 4 days. Overall, a diagnosis of traumatic complication was the most frequently occurring, followed by open wounds, contusions, sprains and strains, and fractures. E-codes were not readily recorded., Conclusion: The use of injury-related acute medical care varied by demographic variables and diagnosis. Findings from this study can be used as a baseline for further surveillance, and to guide the development of interventions to contain preventable injuries and associated treatment costs.