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PURPOSE OF REVIEW: A critical component of any rehabilitation program following injury is a graduated exposure of pathologic or vulnerable tissue to sport-specific stressors. A foundational aspect in the return to sport process following an injury in baseball athletes is the development of an interval throwing program. A shift has occurred in recent years from generic programs to individualized progressions. The current review explores the evolution of interval throwing program construction and discusses the possibilities of the future with advancements in technology and understanding. RECENT FINDINGS: Early interval throwing programs relied primarily on pre-determined throwing distance and volume to estimate total training load while following a fixed throwing schedule. Currently, clinicians have begun to utilize available technology in attempts to determine training prescription and obtain more accurate estimates of stresses placed upon the body. Thus, interval throwing programs have become more individualized and flexible to account for each athlete’s individual differences and biological response to training. Future development may be able to predict specific internal response to stressors and proactively adjust training load to maximize positive adaptations while minimizing any maladaptive events. SUMMARY: As with all concepts and principles within the realm of athlete rehabilitation, clinicians must continue to adapt how they conceptualize and develop individualized interval throwing programs for the overhead throwing athlete. We will continue to see a shift away from a responsive approach to a proactive one, where clinicians can utilize modern technologies to precisely prescribe a throwing dosage based upon expected tissue response within the athlete.

Biologics have become the forefront of medicine for management of autoimmune conditions, leading to improved quality of life. Many autoimmune conditions occur in solid organ transplant (SOT) recipients and persist following transplant. However, the use of biologics in this patient population is not well studied, and questions arise related to risk of infection and adjustments to induction and maintenance immunosuppression. Guidelines have been published highlighting management strategies of biologics around the time of elective surgical procedures, but this is not always feasible in urgent situations, especially with deceased donor transplantation. The aim of this review is to summarize the current literature regarding the use of these agents in solid organ transplant recipients, and specifically address induction and maintenance immunosuppression, as well as the need for alternative infective prevention strategies to create a practical reference for the frontline clinician, when faced with this complex clinical scenario.

Antibody-Mediated Rejection (AMR) due to donor-specific antibodies (DSA) is associated with poor outcomes after lung transplantation. Currently, there are no guidelines regarding the selection of treatment protocols. We studied how DSA characteristics including titers, C1q, and mean fluorescence intensity (MFI) values in undiluted and diluted sera may predict a response to therapeutic plasma exchange (TPE) and inform patient prognosis after treatment. Among 357 patients consecutively transplanted without detectable pre-existing DSAs between 01/01/16 and 12/31/18, 10 patients were treated with a standardized protocol of five TPE sessions with IVIG. Based on DSA characteristics after treatment, all patients were divided into three groups as responders, partial responders, and nonresponders. Kaplan-Meier Survival analyses showed a statistically significant difference in patient survival between those groups (P = 0.0104). Statistical analyses showed that MFI in pre-TPE 1:16 diluted sera was predictive of a response to standardized protocol (R2 = 0.9182) and patient survival (P = 0.0098). Patients predicted to be nonresponders who underwent treatment with a more aggressive protocol of eight TPE sessions with IVIG and bortezomib showed improvements in treatment response (P = 0.0074) and patient survival (P = 0.0253). Dilutions may guide clinicians as to which patients would be expected to respond to a standards protocol or require more aggressive treatment.

This article presents the current state of the literature regarding the use of simulation in the field of paramedicine. It provides the reader with an overview on the current knowledge with the view to inform and foster innovation and development around simulation in paramedic education. We hope that other researchers will use this work to further inform and develop their simulations, not only for the purposes of assessment but also for learning and teaching in paramedicine.

Background: There remains room for improvement in surgical outcomes after medial ulnar collateral ligament reconstruction (MUCLR) in professional pitchers. The role and influence of postoperative rehabilitation on the outcomes of MUCLR are unknown. There is a paucity of clinical data in the current literature comparing the success of various postsurgical rehabilitation protocols after MUCLR. Purpose: To summarize the current rehabilitation process for professional pitchers recovering from MUCLR, evaluates what player and surgical factors correlate with outcomes, and determines whether rehabilitation timing and milestones correlate with successful outcomes. Study Design: Case series; Level of evidence, 4. Methods: 717 professional baseball pitchers who underwent MUCLR between 2010 and 2016 were identified and included in the analysis. Player characteristics evaluated included age at the time of surgery, throwing side dominance, primary pitching role (starter vs reliever), and level of play (MLB, AAA, AA, A). Surgical factors studied included date of surgery, graft type (palmaris longus autograft vs gracilis autograft), and surgical technique (figure of 8 vs docking vs other). The rehabilitation and throwing progression details were as follows: initiation date; first throw date; dates to start throwing from various distances; longest distance thrown; first flat ground throw date; first mound throw date; and first live batting practice (BP) date. The primary outcomes of interest were the ability to return to play at any level (RTP), the ability to return to the same level (RSL), and the time to RTP/RSL. Results: On average, pitchers threw a baseball for the first time 4.9 months after surgery, with a broad range (2.8-14.9 months). For the 675 (94%) pitchers who were able to progress to mound throwing, the first throws off a mound occurred at a mean of 9.4 months after surgery. Before progressing to the mound, the mean longest long-toss distance reached was 137.5 feet, with a broad range (105-300 feet). A high variation in the time to RTP (7.6-53.9 months) and RSL (8.6-60.7 months) was noted. A total of 599 (84%) pitchers were able to RTP at a mean time of 14.9 ± 4.9 months after surgery (range, 7.6-53.9 months). Also, 528 (74%) pitchers were able to RSL after MUCLR at a mean of 17.4 ± 7 months (range, 8.6-60.7 months) postoperatively. Age was the most significant predictor of RTP (hazard ratio [HR], 1.03 [95% CI, 1.01-1.05]; P = .01) and RSL (HR, 0.96 [95% CI, 0.93-0.99]; P < .01). For every 1-year increase in age, there was a 3% increase in the chance of RTP. Conversely, for every 1-year decrease in age, there was a 4% increase in the chance of RSL. MLB players were more likely to RTP (HR, 1.39 [95% CI, 1.18-1.63]; P < .01) but not necessarily to RSL (HR, 0.90 [95% CI, 0.75-1.08]; P = .24). The time from surgery to any of the rehabilitation milestones of interest (first throw, first flat ground pitching, first mound throwing, and first live BP) did not correlate with RTP or RSL (all, P >.05). The same was true for the greatest long-toss distance thrown before transitioning to the mound. Conclusion: Significant variability in the postoperative rehabilitation protocols after MUCLR was observed in 717 professional baseball pitchers. The timing of achievement of throwing progression and rehabilitation milestones postoperatively varied widely but did not correlate with outcomes. Player characteristics—except for player age and professional pitching level—did not correlate with RTP and RSL outcomes. Older pitchers and MLB pitchers were more likely to RTP, but younger players were more likely to RSL. Surgical factors did not correlate with rehabilitation outcomes.

Introduction This paper discusses a trial of the use of CompTracker© – an online platform used to link the student, preceptor and academic in a time sensitive manner during student clinical placement – within a cohort of 330 first and second year paramedic students studying at an Australian university. CompTracker© allows for preceptors to identify and assess clinical competencies, and for the student to reflect after each case is completed on placement. The tool was initially piloted, and then remodeled on several attempts to improve its overall functionality and relevance for the placement learning experience. The study aims to educate and inform other health disciplines that may have an interest in using online tools for competency tracking and education in diverse workplaces. Methods Multiple surveys were conducted over a 3-year period, using both Likert 5-point scales and open-ended questions, to evaluate 330 first and second year students’ and 261 preceptors’ experiences. Results Of the 54 student responses, 92% felt the tool was useful and 67% felt it was easy to use. Within the preceptor results, 63 ± 2% preferred CompTracker© over traditional paper-based methods. Conclusion CompTracker© can be used to support students and preceptors in clinical placement. The flexibility of this online tool makes it adaptable to most clinical workplaces, and should be considered in any workplace that requires the use of competency-based clinical assessment and used in place of traditional paper-based portfolios.

Background Infection with the novel severe acute respiratory syndrome coronavirus 2 has been associated with a hypercoagulable state. Emerging data from China and Europe have consistently shown an increased incidence of venous thromboembolism (VTE). We aimed to identify the VTE incidence and early predictors of VTE at our high-volume tertiary care center. Methods We performed a retrospective cohort study of 147 patients who had been admitted to Temple University Hospital with coronavirus disease 2019 (COVID-19) from April 1, 2020 to April 27, 2020. We first identified the VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]) incidence in our cohort. The VTE and no-VTE groups were compared by univariable analysis for demographics, comorbidities, laboratory data, and treatment outcomes. Subsequently, multivariable logistic regression analysis was performed to identify the early predictors of VTE. Results The 147 patients (20.9% of all admissions) admitted to a designated COVID-19 unit at Temple University Hospital with a high clinical suspicion of acute VTE had undergone testing for VTE using computed tomography pulmonary angiography and/or extremity venous duplex ultrasonography. The overall incidence of VTE was 17% (25 of 147). Of the 25 patients, 16 had had acute PE, 14 had had acute DVT, and 5 had had both PE and DVT. The need for invasive mechanical ventilation (adjusted odds ratio, 3.19; 95% confidence interval, 1.07-9.55) and the admission D-dimer level ≥1500 ng/mL (adjusted odds ratio, 3.55; 95% confidence interval, 1.29-9.78) were independent markers associated with VTE. The all-cause mortality in the VTE group was greater than that in the non-VTE group (48% vs 22%; P = .007). Conclusions Our study represents one of the earliest reported from the United States on the incidence rate of VTE in patients with COVID-19. Patients with a high clinical suspicion and the identified risk factors (invasive mechanical ventilation, admission D-dimer level ≥1500 ng/mL) should be considered for early VTE testing. We did not screen all patients admitted for VTE; therefore, the true incidence of VTE could have been underestimated. Our findings require confirmation in future prospective studies.

According to USDA ERS forecasts in early 2020, median farm income earned by farm households increased in 2019 to -$1,383 from -$1,735 in 2018 but was expected to decline to -$1,840 in 2020 The Farm Bill's structure attests to the fact that nutrition and soil conservation are inextricably related in a much larger system of production, distribution and consumption, and need to be governed and analyzed as such [ ]the term ‘renewable’ encompasses the urgency of Farm Bill logistics—it is iterative, being passed every 5 to 7 years [ ]it must acknowledge the dynamics of racism, sexism and other axes of discrimination in US agricultural policy, and community-led initiatives working to overcome them (White 2011;Doan-Crider et al , 2013;Graddy-Lovelace, 2016;Fagundes et al , 2020) Reading the Farm Bill: major themes and titles Commodity policy and crop insurance The past four decades of federal farm policy has seen a general shift away from supporting farm commodity prices with commodity reserves, marketing

Farm subsidies have become increasingly maligned in agricultural policy debates, but the merits of subsidies are a distraction from deeper political, economic, and ecological problems in agriculture. Drawing on a history of the U.S. Farm Bill, this paper argues that a fixation on farm subsidies ignores why they came into being, and more generally glosses over the imperative for modern states to intervene into agricultural economies. Karl Polanyi's 'double movement' framework is used to situate the rise and fall of agricultural supply management within food regime theory. In the second, or surplus food regime, the U.S. government wielded excess commodities as geopolitical tools—even as domestic farm policy labored to contain overproduction, and thus support agrarian viability. In the subsequent corporate food regime, “free market” agriculture displaces and discredits supply management, even as massive government intervention into how food is grown and sold continues. Making space to remember historical price support programs, to situate their accomplishments and limitations, and to recognize residual supply-management mechanisms (such as farm cooperatives and agricultural marketing orders) is crucial for fostering agricultural viability in the US and beyond. Twentieth century supply management had flaws, but it cannot be wholly omitted. This paper highlights key motivations, elements, and contradictions of these policies and programs to begin the process of considering how supply management principles and strategies could be updated and enhanced for 21st century agriculture. Such a framework would need to pay more attention to diversity within domestic and international agricultures, and be more sensitive to the multi-scalar dimensions of food systems.

BackgroundCorneal transplant failure with neovascularisation is a leading indication for full-thickness grafts in patients. Lymphangiogenesis is implicated in the pathology of graft failure, and here we systematically evaluate failed human corneal transplants with neovascularisation for the presence of lymphatic vessels.MethodsNine failed grafts with neovascularisation, based on H&E staining with subsequent immunoperoxidase staining for CD31, a blood vessel marker, were selected. Lymphatics were investigated by immunohistochemical and immunofluorescence approaches using podoplanin as a lymphatic marker. In two of nine cases, fluorescence in situ hybridisation (FISH) was used for detection of lymphatic mRNAs including podoplanin, VEGFR-3 and LYVE-1. All immunofluorescence and FISH samples were compared with positive and negative controls and visualised by confocal microscopy.ResultsCorneal neovascularisation was established in all cases by H&E and further confirmed by CD31 immunoreactive profiles. Immunohistochemistry for the podoplanin antibody was positive in all cases and showed morphologies ranging from distinct luminal structures to elongated profiles. Simultaneous immunofluorescence using CD31 and podoplanin showed lymphatic vessels distinct from blood vessels. Podoplanin immunofluorescence was noted in seven of nine cases and revealed clear lumina of varying sizes, in addition to lumen-like and elongated profiles. The presence of lymphatic mRNA was confirmed by FISH studies using a combination of at least two of podoplanin, VEGFR-3 and LYVE-1 mRNAs.ConclusionsThe consistent finding of lymphatic vessels in failed grafts with neovascularisation implicates them in the pathogenesis of corneal transplant failure, and points to the lymphatics as a potential new therapeutic target.

An analysis of how the organic dairy commodity chain in the Northeast United States is structured uncovers significant power asymmetries and conflicting tendencies regarding the treadmill of production in organic dairy farming, distribution, and marketing, thus calling into the question the capacity of the state to simultaneously promote markets and transform agriculture in the direction of ecological sustainability. While organic certification has contributed to highly centralized business structures and more advanced processing technology at the distribution and marketing levels, it has also fostered significant changes in farming practices that represent a shift away from intensification and industrialization of agriculture. The standards governing organic dairy production require a slowing down of bovine metabolism and an overall reduction in material throughput, even as the economic system flowing from this regulatory regime has led to changes in milk processing, distribution, and economic control that constitute an acceleration of the treadmill of production.

Urbanization historically has increased the severity of waste-management problems as there is more waste produced per acre, and the growth of residential settlement makes it increasingly difficult to get waste "out of sight, out of mind" conveniently and cheaply. Industrialization compounds the problems of urbanization as rising incomes lead to greater production of waste per capita. In Los Angeles, rapid urbanization starting in the late nineteenth and early twentieth centuries led to the emergence of waste management as an issue of concern to municipal authorities. Later, as the metropolitan area dramatically expanded both geographically and in terms of population, the amount of waste produced escalated while the opportunities for easily disposing of it became fewer and further between. Municipal officials have constantly tinkered with new technologies, or new versions of old technologies, as they have sought solutions to this seemingly intractable problem of how to manage the discards of urbanindustrial society without bankrupting the public treasury, inducing political rebellion, or causing intolerable environmental damage. The history of waste management in Los Angeles is a particularly clear-cut story of how urban growth continually undermines the capacity of local authorities to effectively address environmental externalities produced by urban

In response to low margins in traditional commodity markets and consumer demand for decommodified food, food value chains have emerged in the last decade as strategies for differentiating farm products and opening new, more financially viable market channels for smaller farmers. These business networks incorporate strategic coordination between food producers, distributors, and sellers in pursuit of common financial and social goals. Our analysis of the aggregation, distribution and marketing functions of eight food value chains of diverse character across the United States reveals four summary findings that encapsulate the challenges and opportunities facing these business organizations: (1) private infrastructure investment should match the organizational stage of development and market capacities; (2) identity preservation is a critical market differentiation strategy; (3) informal networks can be highly effective tools for coordinating the marketing efforts of diverse agricultural producers; and (4) nonprofits and cooperatives both can play key roles in value chain development, but should recognize their organizational competencies and limitations.

Extensive research exists on who does or might purchase organic food products, however little research has addressed either who values organic production methods when deciding what to eat, and correspondingly, who does not purchase organics regularly. This paper reports that values about organic farming often do not translate into corresponding stated preferences about organic food consumption behavior. The paradox is examined within the context of the consumers socio-demographic characteristics as well as through opinions and preferences related to food in their lives.Results show that consumer claims of buying organics and placing importance on organic production systems when deciding what to eat are highly correlated (.472 at 1% significance level; p

In a demographically and geographically representative US-based telephone survey of 1201 persons in 2003, it was found as expected that those who purchase organic foods tend to consider organic production methods when they decide what foods to eat. Yet a number of surprising sub-groups showed a disconnect between those who buy organics and those who place importance on organic production. For example, the religiously observant and those for whom food plays an integral role in their lives (eating for pleasure, love, and tradition), on lower income or with less education are more interested in how food is produced than are higher income and more educated groups. We argue that these sub-groups may be overlooked in industry and public policy decisions related to organic food markets and production. Additionally, the highly correlated high income and more education subgroups who purchase organics may be doing so more because of fashion and peer-related influence than because they place importance on organic production methods. (However, women both buy organics frequently and think about organic production methods in their eating decisions.) These findings complicate the literature that shows simpler relationships between organic purchases and education and income. We suggest that further research needs to be done on the influence of affordability, availability, and trust in labeling on organic purchases and support for organic production systems.