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IntroductionNon-fatal shooting rates vary tremendously within cities in the USA. Factors related to structural racism (both historical and contemporary) could help explain differences in non-fatal shooting rates at the neighbourhood level. Most research assessing the relationship between structural racism and firearm violence only includes one dimension of structural racism. Our study uses an intersectional approach to examine how the interaction of two forms of structural racism is associated with spatial non-fatal shooting disparities in Baltimore, Maryland.MethodsWe present three additive interaction measures to describe the relationship between historical redlining and contemporary racialized economic segregation on neighbourhood-level non-fatal shootings.ResultsOur findings revealed that sustained disadvantage census tracts (tracts that experience contemporary socioeconomic disadvantage and were historically redlined) have the highest burden of non-fatal shootings. Sustained disadvantage tracts had on average 24 more non-fatal shootings a year per 10 000 residents compared with similarly populated sustained advantage tracts (tracts that experience contemporary socioeconomic advantage and were not historically redlined). Moreover, we found that between 2015 and 2019, the interaction between redlining and racialized economic segregation explained over one-third of non-fatal shootings (approximately 650 shootings) in sustained disadvantage tracts.ConclusionThese findings suggest that the intersection of historical and contemporary structural racism is a fundamental cause of firearm violence inequities in Baltimore. Intersectionality can advance injury prevention research and practice by (1) serving as an analytical tool to expose inequities in injury-related outcomes and (2) informing the development and implementation of injury prevention interventions and policies that prioritise health equity and racial justice.

Extreme precipitation events (EPE) change the natural and built environments and alter human behavior in ways that facilitate infectious disease transmission. EPEs are expected with high confidence to increase in frequency and are thus of great public health importance. This scoping review seeks to summarize the mechanisms and severity of impacts of EPEs on infectious diseases, to provide a conceptual framework for the influence of EPEs on infectious respiratory diseases, and to define areas of future study currently lacking in this field. The effects of EPEs are well-studied with respect to enteric, vector-borne, and allergic illness where they are shown to moderately increase risk of illness, but not well-understood in relation to infectious respiratory illness. We propose a framework for a similar influence of EPEs on infectious respiratory viruses through several plausible pathways: decreased UV radiation, increased ambient relative humidity, and changes to human behavior (increased time indoors and use of heating and cooling systems). However, limited work has evaluated meteorologic risk factors for infectious respiratory diseases. Future research is needed to evaluate the effects of EPEs on infectious respiratory diseases using individual-level case surveillance, fine spatial scales, and lag periods suited to the incubation periods of the disease under study, as well as a full characterization of susceptible, vulnerable, and sensitive population characteristics.

Background: There has been a renewed interest in ulnar collateral ligament (UCL) repair in overhead athletes because of a greater understanding of UCL injuries, an improvement in fixation technology, and the extensive rehabilitation time to return to play. Purpose/Hypothesis: To evaluate the clinical outcomes of a novel technique of UCL repair with internal brace augmentation in overhead throwers. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing a novel technique of UCL repair with internal brace augmentation were prospectively followed for a minimum of 1 year. Potential candidates for repair were selected after the failure of nonoperative treatment when imaging suggested a complete or partial avulsion of the UCL from either the sublime tubercle or medial epicondyle, without evidence of poor tissue quality of the ligament. The final decision on UCL repair or traditional reconstruction was determined intraoperatively. Demographic and operative data were collected at the time of surgery. Return to play, and Kerlan-Jobe Orthopaedic Clinic (KJOC) scores were collected at 1 year and then again at 2 years postoperatively. Results: Of the 111 overhead athletes eligible for the study, 92% (102/111) of those who desired to return to the same or higher level of competition were able to do so at a mean time of 6.7 months. These patients had a mean KJOC score of 88.2 at final follow-up. Conclusion: UCL repair with internal brace augmentation is a viable option for amateur overhead throwers with selected UCL injuries who wish to return to sport in a shorter time frame than allowed by traditional UCL reconstruction.

ContextHigh loads in the elbow during baseball pitching can lead to serious injuries, including injuries to the ulnar collateral ligament. These injuries have substantial implications for individual pitchers and their teams, especially at the professional level of competition. With a trend toward increased ball velocity in professional baseball, controversy still exists regarding the strength of the relationship between ball velocity and elbow-varus torque.ObjectiveTo examine the relationship between fastball velocity and elbow-varus torque in professional pitchers using between- and within-subjects statistical analyses.DesignCross-sectional study.SettingMotion-analysis laboratory.Patients or Other ParticipantsUsing the previously collected biomechanical data of 452 professional baseball pitchers, we performed a retrospective analysis of the 64 pitchers (52 right-hand dominant, 12 left-hand dominant; age = 21.8 ± 2.0 years, height = 1.90 ± 0.05 m, mass = 94.6 ± 7.8 kg) with fastball velocity distributions that enabled between- and within-subjects statistical analyses.Main Outcome Measure(s)We measured ball velocity using a radar gun and 3-dimensional motion data using a 12-camera automated motion-capture system sampling at 240 Hz. We calculated elbow-varus torque using inverse-dynamics techniques and then analyzed the relationship between ball velocity and elbow torque using both a simple linear regression model and a mixed linear model with random intercepts.ResultsThe between-subjects analyses displayed a weak positive association between ball velocity and elbow-varus torque (R2 = 0.076, P = .03). The within-subjects analyses showed a considerably stronger positive association (R2 = 0.957, P < .001).ConclusionsWhen comparing 2 professional baseball pitchers, higher velocity may not necessarily indicate higher elbow-varus torque due to the confounding effects of pitcher-specific differences (eg, detailed anthropometrics and pitching mechanics). However, within an individual pitcher, higher ball velocity was strongly associated with higher elbow-varus torque.

Background This study aims to assess the COVID-19 response preparedness of the Mozambican health system by 1) determining the location of oxygen-ready public health facilities, 2) estimating the oxygen treatment capacity, and 3) determining the population coverage of oxygen-ready health facilities in Mozambique. Methods This analysis utilizes information on the availability of oxygen sources and delivery apparatuses to determine if a health facility is ready to deliver oxygen therapy to patients in need, and estimates how many patients can be treated with continuous oxygen flow for a 7-day period based on the available oxygen equipment at health facilities. Using GIS mapping software, the study team modeled varying travel times to oxygen-ready facilities to estimate the proportion of the population with access to care. Results 0.4% of all health facilities in Mozambique are prepared to deliver oxygen therapy to patients, for a cumulative total of 283.9 to 406.0 patients-weeks given the existing national capacity, under varying assumptions including ability to divert oxygen from a single source to multiple patients. 35% of the population in Mozambique has adequate access within one-hour driving time of an oxygen-ready health facility. This varies widely by region; 89.1% of the population of Maputo City was captured by the one-hour driving time network, as compared ot 4.4% of the population of Niassa province. Conclusions The Mozambican health system faces the dual challenges of under-resourced health facilities and low geographic accessibility to healthcare as it prepares to confront the COVID-19 pandemic. This analysis also illustrates the disparity between provinces in preparedness to deliver oxygen therapy to patient, with Cabo Delgado and Nampula being particularly under-resourced.

Objectives Hepcidin measurement advances insights in pathophysiology, diagnosis, and treatment of iron disorders, but requires analytically sound and standardized measurement procedures (MPs). Recent development of a two-level secondary reference material (sRM) for hepcidin assays allows worldwide standardization. However, no proficiency testing (PT) schemes to ensure external quality assurance (EQA) exist and the absence of a high calibrator in the sRM set precludes optimal standardization. Methods We developed a pilot PT together with the Dutch EQA organization Stichting Kwaliteitsbewaking Medische Laboratoriumdiagnostiek (SKML) that included 16 international hepcidin MPs. The design included 12 human serum samples that allowed us to evaluate accuracy, linearity, precision and standardization potential. We manufactured, value-assigned, and validated a high-level calibrator in a similar manner to the existing low- and middle-level sRM. Results The pilot PT confirmed logistical feasibility of an annual scheme. Most MPs demonstrated linearity (R2>0.99) and precision (duplicate CV>12.2%), although the need for EQA was shown by large variability in accuracy. The high-level calibrator proved effective, reducing the inter-assay CV from 42.0% (unstandardized) to 14.0%, compared to 17.6% with the two-leveled set. The calibrator passed international homogeneity criteria and was assigned a value of 9.07±0.24 nmol/L. Conclusions We established a framework for future PT to enable laboratory accreditation, which is essential to ensure quality of hepcidin measurement and its use in patient care. Additionally, we showed optimized standardization is possible by extending the current sRM with a third high calibrator, although international implementation of the sRM is a prerequisite for its success.

ObjectiveThis study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA).SettingSurgical and anaesthesia services across all levels of care—primary, secondary and tertiary.DesignWe performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing.ResultsThe search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives.ConclusionFinancing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.

Background: Few studies have documented the outcomes of superior labral anterior-posterior (SLAP) repairs in baseball players. Furthermore, the results of these previous studies varied widely and were based on small numbers of patients. Hypothesis/Purpose: The purpose was to report return-to-play (RTP) rates and validated subjective outcome scores for baseball players after SLAP repair. It was hypothesized that RTP rates and outcomes would be significantly different between pitchers and nonpitchers, as well as among baseball levels. Study Design: Case series; Level of evidence, 4. Methods: A series of 216 baseball players was identified who had isolated SLAP repair or SLAP repair with debridement of partial-thickness (Results: Of the 216 baseball players, 133 were reached by phone for follow-up interview (mean, 78 months; range, 27-146 months). Overall, 62% successfully returned to play. There were no differences in RTP rates or subjective outcomes among baseball levels or between procedures. RTP rates were 59% for pitchers and 76% for nonpitchers ( P = .060). Subjectively, the percentage of patients who felt the same or better at follow-up compared to preinjury was significantly higher among nonpitchers (66%) than pitchers (43%). There was no difference in KJOC scores between the pitchers (75.3 ± 19.4) and nonpitchers (76.2 ± 17.4) who successfully returned to play, although these scores were well below the minimum desired score of 90 for healthy baseball players. Conclusion: SLAP repair should continue to be considered as an option for SLAP tear treatment only after nonsurgical management has failed. Some players may be able to return to baseball after SLAP repair, although regaining preinjury health and performance is challenging.

The purpose of this study was to determine how often flaws in pitching mechanics identified from biomechanical analysis are corrected. The biomechanics of 46 baseball pitchers were evaluated twice, with an average of 12 months (range 2-48 months) between evaluations. Pitchers were healthy at the time of both evaluations, competing at the high school, college, minor league or Major League level. After warming up, each participant pitched 10 full-effort fastballs. Automated three-dimensional motion analysis was used to compute eight kinematic parameters which were compared with a database of elite professional pitchers. Flaws-defined as deviations from the elite range-were explained to each participant or coach after his initial evaluation. Data from the second evaluation revealed that 44% of all flaws had been corrected. Flaws at the instant of foot contact (stride length, front foot position, shoulder external rotation, shoulder abduction, elbow flexion) or slightly after foot contact (time between pelvis rotation and upper trunk rotation) seemed to be corrected more often than flaws near the time of ball release (knee extension and shoulder abduction). Future research may determine which level athletes or which training methods are most effective for correcting flaws.

Background:Anterior cruciate ligament (ACL) injuries occur commonly in football. Recent work has reported ACL reconstruction (ACLR) as one of several orthopaedic procedures with unfavorable outcomes for professional athletes. The performance impact to defensive players after surgery has not been quantified.Purpose:To quantify the effect of ACLR on the performance of defensive players by comparing them to a cohort of matched controls as well as to measure the effect of ACLR on athletes’ career length in the National Football League (NFL).Study Design:Case-control and cohort study; Level of evidence, 3.Methods:Thirty-eight NFL defensive players with a history of ACLR from 2006 to 2012 were identified. For each injured player, a matched control player was identified. Demographic and performance statistics were collected from the online NFL player database. Players who returned after ACLR (n = 23) were compared with players who did not return (n = 15) using t tests and chi-squared analyses. Similarly, players who returned after ACLR (n = 23) were compared with their matched controls with t tests and chi-squared analyses. Two-way repeated-measures analysis of variance was utilized to test for significant differences between performance before and after the season of the injury for the players in the ACLR group who returned (n = 23) and for their matched controls. Kaplan-Meier analysis was performed to test for differences in the rate of retirement between the groups. For all analyses, P values Results:Approximately 74% (28/38) of athletes who underwent ACLR returned to play at least 1 NFL game, and 61% (23/38) successfully returned to play at least half a season (ie, 8 games). Athletes in the ACLR group who returned retired from the NFL significantly sooner and more often after surgery than their matched controls. In the seasons leading up to their injury, athletes who successfully returned to play started a greater percentage of their games (81%) and made more solo tackles per game (3.44 ± 1.47) compared with athletes in the ACLR group who did not return to play (54% and 1.82 ± 1.17, respectively) and compared with healthy control players (52% and 1.77 ± 1.19, respectively). After the season of surgery, athletes in the ACLR group who returned to play decreased to 57% games started and 2.38 ± 1.24 solo tackles per game, while their matched controls suffered no significant decreases.Conclusion:Players who successfully returned were above-average NFL players before their injury but comparatively average after their return.

Purpose: Advanced glycation end products (AGEs) can be formed in foods by the reaction of reducing sugars with proteins, and have been shown to induce insulin resistance and obesity in experimental studies. We examined the association between dietary AGEs intake and changes in body weight in adults over an average of 5 years of follow-up. Methods: A total of 255,170 participants aged 25–70 years were recruited in ten European countries (1992–2000) in the PANACEA study (Physical Activity, Nutrition, Alcohol, Cessation of smoking, Eating out of home in relation to Anthropometry), a sub-cohort of the EPIC (European Prospective Investigation into Cancer and Nutrition). Body weight was measured at recruitment and self-reported between 2 and 11 years later depending on the study center. A reference database for AGEs was used containing UPLC–MS/MS-measured Nε-(carboxymethyl)-lysine (CML), Nε-(1-carboxyethyl)-lysine (CEL), and Nδ-(5-hydro-5-methyl-4-imidazolon-2-yl)-ornithine (MG-H1) in 200 common European foods. This reference database was matched to foods and decomposed recipes obtained from country-specific validated dietary questionnaires in EPIC and intake levels of CEL, CML, and MG-H1 were estimated. Associations between dietary AGEs intake and body weight change were estimated separately for each of the three AGEs using multilevel mixed linear regression models with center as random effect and dietary AGEs intake and relevant confounders as fixed effects. Results: A one-SD increment in CEL intake was associated with 0.111 kg (95% CI 0.087–0.135) additional weight gain over 5 years. The corresponding additional weight gain for CML and MG-H1 was 0.065 kg (0.041–0.089) and 0.034 kg (0.012, 0.057), respectively. The top six food groups contributing to AGEs intake, with varying proportions across the AGEs, were cereals/cereal products, meat/processed meat, cakes/biscuits, dairy, sugar and confectionary, and fish/shellfish. Conclusion: In this study of European adults, higher intakes of AGEs were associated with marginally greater weight gain over an average of 5 years of follow-up. © 2019, Springer-Verlag GmbH Germany, part of Springer Nature.

Aim: To investigate the associations between major foods and dietary fibre with subtypes of stroke in a large prospective cohort. Methods and results: We analysed data on 418 329 men and women from nine European countries, with an average of 12.7 years of follow-up. Diet was assessed using validated country-specific questionnaires which asked about habitual intake over the past year, calibrated using 24-h recalls. Multivariable-adjusted Cox regressions were used to estimate hazard ratios (HRs) for ischaemic and haemorrhagic stroke associated with consumption of red and processed meat, poultry, fish, dairy foods, eggs, cereals, fruit and vegetables, legumes, nuts and seeds, and dietary fibre. For ischaemic stroke (4281 cases), lower risks were observed with higher consumption of fruit and vegetables combined (HR; 95% CI per 200 g/day higher intake, 0.87; 0.82-0.93, P-trend < 0.001), dietary fibre (per 10 g/day, 0.77; 0.69-0.86, P-trend < 0.001), milk (per 200 g/day, 0.95; 0.91-0.99, P-trend = 0.02), yogurt (per 100 g/day, 0.91; 0.85-0.97, P-trend = 0.004), and cheese (per 30 g/day, 0.88; 0.81-0.97, P-trend = 0.008), while higher risk was observed with higher red meat consumption which attenuated when adjusted for the other statistically significant foods (per 50 g/day, 1.07; 0.96-1.20, P-trend = 0.20). For haemorrhagic stroke (1430 cases), higher risk was associated with higher egg consumption (per 20 g/day, 1.25; 1.09-1.43, P-trend = 0.002). Conclusion: Risk of ischaemic stroke was inversely associated with consumption of fruit and vegetables, dietary fibre, and dairy foods, while risk of haemorrhagic stroke was positively associated with egg consumption. The apparent differences in the associations highlight the importance of examining ischaemic and haemorrhagic stroke subtypes separately. © 2020 The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Purpose The prevalence of connective tissue progenitor cells within a cell-based therapy is often quantified using the colony-forming unit fibroblast (CFU-F) assay. The present study investigates the feasibility of using cryopreserved bone marrow aspirate concentrate (BMAC) as an alternative cell source to fresh BMAC for CFU-F quantification. Methods Freshly prepared and corresponding cryopreserved BMAC samples from patients receiving autologous cell therapy (n = 98) were analyzed using the CFU-F assay for comparison. Cultures were established by directly plating BMAC at low cell densities and maintained for a 2-week growth period. Colonies were enumerated to determine CFU-F frequency, and a subset of cultures was imaged and analyzed to quantify colony area and density. Results A nonlinear relationship was observed between plating density and CFU-F frequency over a wide range in plating densities (~30-fold). Cryopreserved BMAC yielded recoverable (77 ± 23%) and viable (73 ± 9%) nucleated cells upon thawing. After cryopreservation, CFU-F frequencies were found to be significantly lower (56.6 ± 34.8 vs. 50.3 ± 31.7 colonies per million nucleated cells). Yet the number of CFU-F in fresh and cryopreserved BMAC were strongly correlated (r = 0.87) and had similar area and densities. Further, moderate correlations were observed between the number of CFU-F and nucleated cells, and both the mean colony area and density were negatively correlated with patient age. Notably, no relationship was found between CFU-F frequency and age, regardless of whether fresh or cryopreserved BMAC was used. Conclusions Freshly prepared and cryopreserved BMAC yielded correlated results when analyzed using the CFU-F assay. Our findings support the cryogenic storage of patient BMAC samples for retrospective CFU-F analyses, offering a potential alternative for characterizing BMAC and furthering our understanding of progenitor cells in relation to clinical outcome.

Background: Weighted-ball throwing programs are commonly used in training baseball pitchers to increase ball velocity. The purpose of this study was to compare kinematics and kinetics among weighted-ball exercises with values from standard pitching (ie, pitching standard 5-oz baseballs from a mound). Hypothesis: Ball and arm velocities would be greater with lighter balls and joint kinetics would be greater with heavier balls. Study Design: Controlled laboratory study. Methods: Twenty-five high school and collegiate baseball pitchers experienced with weighted-ball throwing were tested with an automated motion capture system. Each participant performed 3 trials of 10 different exercises: pitching 4-, 5-, 6-, and 7-oz baseballs from a mound; flat-ground crow hop throws with 4-, 5-, 6-, and 7-oz baseballs; and flat-ground hold exercises with 14- and 32-oz balls. Twenty-six biomechanical parameters were computed for each trial. Data among the 10 exercises were compared with repeated measures analysis of variance and post hoc paired t tests against the standard pitching data. Results: Ball velocity increased as ball mass decreased. There were no differences in arm and trunk velocities between throwing a standard baseball and an underweight baseball (4 oz), while arm and trunk velocities steadily decreased as ball weight increased from 5 to 32 oz. Compared with values pitching from a mound, velocities of the pelvis, shoulder, and ball were increased for flat-ground throws. In general, as ball mass increased arm torques and forces decreased; the exception was elbow flexion torque, which was significantly greater for the flat-ground holds. There were significant differences in body positions when pitching on the mound, flat-ground throws, and holds. Conclusions: While ball velocity was greatest throwing underweight baseballs, results from the study did not support the rest of the hypothesis. Kinematics and kinetics were similar between underweight and standard baseballs, while overweight balls correlated with decreased arm forces, torques, and velocities. Increased ball velocity and joint velocities were produced with crow hop throws, likely because of running forward while throwing. Clinical Relevance: As pitching slightly underweight and overweight baseballs produces variations in kinematics without increased arm kinetics, these exercises seem reasonable for training pitchers. As flat-ground throwing produces increased shoulder internal rotation velocity and elbow varus torque, these exercises may be beneficial but may also be stressful and risky. Flat-ground holds with heavy balls should not be viewed as enhancing pitching biomechanics, but rather as hybrid exercises between throwing and resistance training.

Purpose To determine common mechanisms of anterior cruciate ligament (ACL) injury in baseball players and to quantify the rate of return to play after primary surgical reconstruction and review intermediate clinical outcomes. Methods Surgical injuries involving the ACL in youth, high school, collegiate, and professional baseball players were queried for an 11-year period (2001 to 2011). Over the study period, 42 baseball players were identified who had undergone arthroscopically assisted primary ACL reconstruction by 1 of 3 attending surgeons. Retrospective chart review was performed for all 42 patients to evaluate variables of age, level of competition, position, mechanism of injury, graft choice, and associated meniscal injuries. Twenty-six patients were reached for telephone survey and International Knee Documentation Committee questionnaire and they answered questions about their original injury and playing history. Results The most common mechanism of injury was fielding, followed by base running. Infielders and outfielders (32% each) were the most commonly injured position, followed by pitchers (29%). Among the 32 players for whom it could be determined, 30 (94%) were able to return to playing baseball at a mean follow-up of 4.2 years (range 1.0 to 9.9 years). The mean International Knee Documentation Committee score was 84.0 (range 63 to 91). Among the 26 patients contacted for telephone interview, no one required revision ACL surgery, but 3 required a subsequent procedure for meniscal tear. Twenty-five patients (96%) denied any episodes of instability in the knee after reconstruction. Conclusions The overwhelming majority of baseball players that sustain ACL injuries do so while fielding or base running. Outfielders are significantly more likely than infielders to suffer ACL injuries while fielding versus base running. The results with respect to return to play are promising, as nearly all patients were able to return to baseball and none required a revision ACL surgery at a mean follow-up of 4.2 years. Level of Evidence Level IV, therapeutic case series.

Background: Extreme conditioning programs (ECPs) are fitness training regimens relying on aerobic, plyometric, and resistance training exercises, often with high levels of intensity for a short duration of time. These programs have grown rapidly in popularity in recent years, but science describing the safety profile of these programs is lacking. Hypothesis: The rate of injury in the extreme conditioning program is greater than the injury rate of weightlifting and the majority of injuries occur to the shoulder and back. Study Design: Cross-sectional study. Level of Evidence: Level 4. Methods: This is a retrospective survey of injuries reported by athletes participating in an ECP. An injury survey was sent to 1100 members of Iron Tribe Fitness, a gym franchise with 5 locations across Birmingham, Alabama, that employs exercises consistent with an ECP in this study. An injury was defined as a physical condition resulting from ECP participation that caused the athlete to either seek medical treatment, take time off from exercising, or make modifications to his or her technique to continue. Results: A total of 247 athletes (22%) completed the survey. The majority (57%) of athletes were male (n = 139), and 94% of athletes were white (n = 227). The mean age of athletes was 38.9 years (±8.9 years). Athletes reported participation in the ECP for, on average, 3.6 hours per week (± 1.2 hours). Eighty-five athletes (34%) reported that they had sustained an injury while participating in the ECP. A total of 132 injuries were recorded, yielding an estimated incidence of 2.71 per 1000 hours. The shoulder or upper arm was the most commonly injured body site, accounting for 38 injuries (15% of athletes). Athletes with a previous shoulder injury were 8.1 times as likely to injure their shoulder in the ECP compared with athletes with healthy shoulders. The trunk, back, head, or neck (n = 29, 12%) and the leg or knee (n = 29, 12%) were the second most commonly injured sites. The injury incidence rate among athletes with Conclusion: The estimated injury rate among athletes participating in this ECP was similar to the rate of injury in weightlifting and most other recreational activities. The shoulder or upper arm was the most commonly injured area, and previous shoulder injury predisposed to new shoulder injury. New athletes are at considerable risk of injury compared with more experienced athletes. Clinical Relevance: Extreme conditioning programs are growing in popularity, and there is disagreement between science and anecdotal reports from athletes, coaches, and physicians about their relative safety. This study estimates the incidence of injury in extreme conditioning programs, which appears to be similar to other weight-training programs.

Background: Ulnar collateral ligament (UCL) reconstruction is an increasingly common procedure being performed in overhead throwing athletes. Recently, postoperative imaging has revealed the presence of heterotopic ossification (HO) in symptomatic patients. Purpose: To determine the incidence of symptomatic HO after UCL reconstruction as well as the clinical outcomes after nonoperative or operative treatment of HO. Study Design: Case series, Level of evidence, 4. Methods: A search was performed of diagnostic codes for all UCL reconstructions at a single institution between 2002 and 2012, and the charts were then reviewed of patients who returned to clinic for symptomatic HO after UCL reconstruction. All relevant clinical information, imaging findings, and return-to-play data were obtained. Results: Eight patients were found to have developed symptomatic HO after UCL reconstruction. Of the 8 patients, 6 had gracilis tendon autograft at their primary surgery. All 8 patients had HO on the proximal end of their graft. Two patients were treated nonoperatively, and the remainder had excision of HO performed either arthroscopically or open. Six patients were able to return to the same or higher level of competition after treatment of HO. Conclusion: Symptomatic HO after UCL reconstruction is very uncommon but may prove to be a significant complication among athletes. With appropriate treatment, the majority of patients were able to return to the same level of play. Early identification of this complication is important, as revision surgery with excision of osteophytes resulted in a return to a similar level of play in most patients.

BACKGROUND: Hurricane Katrina made landfall in New Orleans, Louisiana as a Category 3 storm in August 2005. Storm surges, levee failures, and the low-lying nature of New Orleans led to widespread flooding, damage to over 70% of occupied housing, and evacuation of 80–90% of city residents. Only 57% of the city's black population has returned. Many residents complain of gentrification following rebuilding efforts. Climate gentrification is a recently described phenomenon whereby the effects of climate change, most notably rising sea levels and more frequent flooding and storm surges, alter housing values in a way that leads to gentrification. OBJECTIVE: To examine the climate gentrification following hurricane Katrina by (1) estimating the associations between flooding severity, ground elevation, and gentrification and (2) whether these relationships are modified by neighborhood level pre- and post-storm sociodemographic factors. METHODS: Lidar data collected in 2002 were used to determine elevation. Water gauge height of Lake Ponchartrain was used to estimate flood depth. Using census tracts as a proxy for neighborhoods, demographic, housing, and economic data from the 2000 decennial census and the 2010 and 2015 American Community Survey 5-year estimates US Census records were used to determine census tracts considered eligible for gentrification (median income < 2000 Orleans Parish median income). A gentrification index was created using tract changes in education level, population above the poverty limit, and median household income. Proportional odds ordinal logistic regression was used with product terms to test for effect measure modification by sociodemographic factors. RESULTS: Census tracts eligible for gentrification in 2000 were 80.2% black. Median census tract flood depth was significantly lower in areas eligible to undergo gentrification (0.70 m vs. 1.03 m). Residents of gentrification-eligible tracts in 2000 were significantly more likely to be black, less educated, lower income, unemployed, and rent their home rather than own. In 2015 in these same eligible tracts, areas that underwent gentrification became significantly whiter, more educated, higher income, less unemployed, and more likely to live in a multi-unit dwelling. Gentrification was inversely associated with flood depth and directly associated with ground elevation in eligible tracts. Marginal effect modification was detected by the effect of pre-storm black race on the relationships of flood depth and elevation with gentrification. CONCLUSIONS: Gentrification was strongly associated with higher ground elevation in New Orleans. These results provide evidence to support the idea of climate gentrification described in other low-elevation major metropolitan areas like Miami, FL. High elevation, low-income, demographically transitional areas in particular - that is areas that more closely resemble high-income area demographics, may be vulnerable to future climate gentrification.

We present results from deep observations towards the Cygnus region using 300 hours of very-high-energy (VHE) $\gamma$-ray data taken with the VERITAS Cherenkov telescope array and over seven years of high-energy $\gamma$-ray data taken with the Fermi satellite at an energy above 1 GeV. As the brightest region of diffuse $\gamma$-ray emission in the northern sky, the Cygnus region provides a promising area to probe the origins of cosmic rays. We report the identification of a potential Fermi-LAT counterpart to VER J2031+415 (TeV J2032+4130), and resolve the extended VHE source VER J2019+368 into two source candidates (VER J2018+367* and VER J2020+368*) and characterize their energy spectra. The Fermi-LAT morphology of 3FGL 2021.0+4031e (the Gamma-Cygni supernova remnant) was examined and a region of enhanced emission coincident with VER J2019+407 was identified and jointly fit with the VERITAS data. By modeling 3FGL J2015.6+3709 as two sources, one located at the location of the pulsar wind nebula CTB 87 and one at the quasar QSO J2015+371, a continuous spectrum from 1 GeV to 10 TeV was extracted for VER J2016+371 (CTB 87). An additional 71 locations coincident with Fermi-LAT sources and other potential objects of interest were tested for VHE $\gamma$-ray emission, with no emission detected and upper limits on the differential flux placed at an average of 2.3% of the Crab Nebula ux. We interpret these observations in a multiwavelength context and present the most detailed $\gamma$-ray view of the region to date., Comment: 49 Pages, 22 Figures, 13 Tables, Accepted to ApJ

Background: Emphasis on enhancing baseball pitch velocity has become popular, especially through weighted-ball throwing. However, little is known about the physical effects or safety of these programs. The purpose of this study was to examine the effects of training with weighted baseballs on pitch velocity, passive range of motion (PROM), muscle strength, elbow torque, and injury rates. Hypothesis: A 6-week weighted ball training program would result in a change in pitching biomechanical and physical characteristics. Study Design: Randomized controlled trial. Level of Evidence: Level 1. Methods: During the baseball offseason, 38 healthy baseball pitchers were randomized into a control group and an experimental group. Pitch velocity, shoulder and elbow PROM, shoulder strength, elbow varus torque, and shoulder internal rotation velocity were measured in both groups. The experimental group then performed a 6-week weighted ball throwing program 3 times per week using balls ranging from 2 to 32 ounces while the control group only used a 5-ounce regulation baseball. Both groups performed a strength training program. Measurements were then repeated after the 6-week period. Injuries were tracked over the 6-week training program and the subsequent baseball season. The effect of training with a weighted ball program was assessed using 2-way repeated-measures analysis of variance at an a priori significance level of P < 0.05. Results: Mean age, height, mass, and pretesting throwing velocity were 15.3 ± 1.2 years (range, 13-18 years), 1.73 ± 0.28 m, 68.3 ± 11 kg, and 30.3 ± 0.7 m/s, respectively. Pitch velocity showed a statistically significant increase (3.3%) in the experimental group ( P < 0.001). There was a statistically significant increase of 4.3° of shoulder external rotation in the experimental group. The overall injury rate was 24% in the experimental group. Four participants in the experimental group suffered elbow injuries, 2 during the training program and 2 in the season after training. No pitchers in the control group were injured at any time during the study. Conclusion: Performing a 6-week weighted ball throwing program increased pitch velocity. However, the program resulted in increased shoulder external rotation PROM and increased injury rate. Clinical Relevance: Although weighted-ball training may increase pitch velocity, caution is warranted because of the notable increase in injuries and physical changes observed in this cohort.

Background: Recent reports have highlighted the progressive increase in the incidence of ulnar collateral ligament (UCL) injuries to the elbow in baseball players of all levels. However, knowledge of the incidence and other epidemiological factors regarding UCL injuries, specifically in college baseball players, is currently lacking. Purpose: To evaluate, over a period of 1 year, the incidence of UCL injuries requiring surgery in National Collegiate Athletic Association (NCAA) Division I baseball programs. Study Design: Descriptive epidemiology study. Methods: A total of 155 Division I collegiate baseball programs agreed to participate in the study. Demographics (position, year, background [location of high school]) for all players on these rosters were obtained from public websites. At the conclusion of the 2017 collegiate baseball season, the athletic trainer for each program entered anonymous, detailed information on injured players through an electronic survey into a secured database. Results: All 155 teams enrolled in the study completed the electronic survey. Of the 5295 collegiate baseball players on these rosters, 134 underwent surgery for an injured UCL (2.5% of all eligible athletes), resulting in a team surgery rate of 0.86 per program for 1 year. These 134 players came from 88 teams, thus 56.8% of the study teams underwent at least 1 surgery during the year. The surgery rate was 2.5 per 100 player-seasons for all players and was significantly higher among pitchers (4.4/100 player-seasons) than nonpitchers (0.7/100 player-seasons). The surgery rate was also significantly higher in underclassmen (3.1/100 player-seasons among freshmen and sophomores) than upperclassmen (1.9/100 player-seasons among juniors and seniors) (incidence rate ratio, 1.7; 95% CI, 1.1-2.4). Players from traditionally warm-weather states did not undergo UCL surgery at a significantly different rate from players from traditionally cold-weather states (2.7/100 player-seasons vs 2.1/100 player-seasons, respectively). Nearly half of surgeries (48.5%) were performed during the baseball season. Conclusion: The incidence of UCL surgeries in NCAA Division I collegiate baseball players represents substantial morbidity to this young athletic population. Risk factors for injuries requiring surgery include being a pitcher and an underclassman. Awareness of these factors should be considered in injury prevention programs. Furthermore, this initial study can serve as a foundation for tracking these surgical injuries in future years and then identifying trends over time.

While 10% of the general population is left-handed, 27% of professional baseball pitchers are left-handed. Biomechanical differences between left- and right-handed college pitchers have been previously reported, but these differences have yet to be examined at the professional level. Therefore, the purpose of this study was to compare pitching biomechanics between left- and right-handed professional pitchers. It was hypothesised that there would be significant kinematic and kinetic differences between these two groups. Pitching biomechanics were collected on 96 left-handed pitchers and a group of 96 right-handed pitchers matched for age, height, mass and ball velocity. Student

Background: Shoulder injuries from repetitive baseball pitching continue to be a serious, common problem. Purpose: To determine whether passive range of motion of the glenohumeral joint was predictive of shoulder injury or shoulder surgery in professional baseball pitchers. Study Design: Cohort study; Level of evidence, 2. Methods: Passive range of motion of the glenohumeral joint was assessed with a bubble goniometer during spring training for all major and minor league pitchers of a single professional baseball organization over a period of 8 successive seasons (2005-2012). Investigators performed a total of 505 examinations on 296 professional pitchers. Glenohumeral external and internal rotation was assessed with the pitcher supine and the arm abducted to 90° in the scapular plane with the scapula stabilized anteriorly at the coracoid process. Total rotation was defined as the sum of internal and external glenohumeral rotation. Passive shoulder flexion was measured with the pitcher supine and the lateral border of the scapula manually stabilized. After examination, shoulder injuries and injury durations were recorded by each pitcher’s respective baseball organization and reported to the league as an injury transaction as each player was placed on the disabled list. Results: Highly significant side-to-side differences were noted within subjects for each range of motion measurement. There were 75 shoulder injuries and 20 surgeries recorded among 51 pitchers, resulting in 5570 total days on the disabled list. Glenohumeral internal rotation deficit, total rotation deficit, and flexion deficit were not significantly related to shoulder injury or surgery. Pitchers with insufficient external rotation (Conclusion: Insufficient shoulder external rotation on the throwing side increased the likelihood of shoulder injury and shoulder surgery. Sports medicine clinicians should be aware of these findings and develop a preventive plan that addresses this study’s findings to reduce pitchers’ risk of shoulder injury and surgery.

Objectives: Injuries involving fractures of the metacarpals are common among football players of all levels. These injuries are typically treated conservatively with casting or splinting among non-in-season athletes, a method that involves a relatively lengthy recovery time (four weeks). To our knowledge, there are no previous reports documenting return to play in elite football players after operative management of metacarpal fractures. The purpose of this study was to retrospectively review and describe the results of operative treatment of metacarpal shaft fractures in 19 high level football players with respect to return to play. We hypothesized that in-season football players with metacarpal fractures treated surgically would be able to return to play more quickly than the typical recovery time following non-operative treatment. Methods: Surgically treated metacarpal fractures in elite football players were queried over a three-year period (2009-2012) from a database maintained by American Sports Medicine Institute (ASMI) in Birmingham, AL. Over the study period, 19 football players were identified who underwent open reduction internal fixation of metacarpal fractures by one of three attending surgeons. Retrospective chart review and phone interviews with the patient and their athletic trainers were performed to identify player position, level of competition, mechanism of injury, return to play, post-operative bracing, and re-fracture event. Radiographs were used to classify the fractures, and operative reports were reviewed for implant choice. Numerical means were calculated for in-season return to play as well as for brace time. Results: Ten high school players (53%) and nine college players (47%) were injured. The most common injured positions were wide receivers and defensive backs (26% each). Most injuries occurred through player to player contact (63%) at a game (37%) or practice (47%). The long finger (58%) was the most commonly involved metacarpal. Two players (11%) had multiple metacarpal fractures. The most common location was mid-diaphyseal (74%). Twelve patients were stabilized with plates and screws, five of whom underwent lag screw augmentation. Six patients were stabilized with a metacarpal nail and one was stabilized with only lag screws. All athletes were able to return to their pre-injury level of play without recurrence of fracture. Return to play for in-season athletes (N=11) was 6.3 days. The average time to return to play for in-season high school football players (N=6) was 9.2 days and 2.8 days for in-season collegiate football players (N=5). All in-season athletes returned to play with protective equipment in the form of a padded glove, bivalve padded cast, padded club cast, or padded splint. The protective equipment was used for an average of 21 days. Conclusion: This study provides support for the surgical treatment of displaced metacarpal shaft fractures with immediate return to play as tolerated for in-season football players. No re-fractures or complications were identified with the use of a plate, nail, or with lag screws. Elite football players can return to play with or without protective bracing depending on the position played and within a week of operative fixation.

Primordial Black Holes (PBHs) are gravitationally collapsed objects that may have been created by density fluctuations in the early universe and could have arbitrarily small masses down to the Planck scale. Hawking showed that due to quantum effects, a black hole has a temperature inversely proportional to its mass and will emit all species of fundamental particles thermally. PBHs with initial masses of ~5.0 x 10^14 g should be expiring in the present epoch with bursts of high-energy particles, including gamma radiation in the GeV - TeV energy range. The Milagro high energy observatory, which operated from 2000 to 2008, is sensitive to the high end of the PBH evaporation gamma-ray spectrum. Due to its large field-of-view, more than 90% duty cycle and sensitivity up to 100 TeV gamma rays, the Milagro observatory is well suited to perform a search for PBH bursts. Based on a search on the Milagro data, we report new PBH burst rate density upper limits over a range of PBH observation times. In addition, we report the sensitivity of the Milagro successor, the High Altitude Water Cherenkov (HAWC) observatory, to PBH evaporation events., Comment: Accepted to Astroparticle Physics Journal (25 Pages, 3 figures and 7 tables). Corresponding author: T. N. Ukwatta

Background: Knee injuries, including articular cartilage damage, are common in football players and are potentially career threatening. The rate of return to play (RTP) as well as the factors affecting return after arthroscopic chondroplasty of the knee is performed in National Football League (NFL) athletes are not known. Purpose: To determine the rate of return to regular season NFL competition after arthroscopic knee surgery including chondroplasty of articular cartilage lesions. In addition, identification of factors that influence successful return was investigated. Study Design: Case series; Level of evidence, 4. Methods: Athletes in the NFL who underwent arthroscopic chondroplasty at a single institution were identified. Retrospective chart review and review of the NFL online database were utilized to determine the rate of RTP and factors affecting an athlete’s ability to return. Chi-square and Student t tests were used to assess differences among players who were and were not able to RTP, and logistic regression was employed to determine a player’s odds of return. Results: There were 52 patients (54 procedures) identified from the surgical database who met the inclusion criteria for the study operated on between August 1, 2001, and March 31, 2011. Of these players, 36 (67%) were able to return to regular season NFL game play at an average of 8.2 months, including 13 (24%) who were still active in the NFL. The average time to follow-up was 5.9 years, and all players were allowed at least 2 years of follow-up. There was no significant correlation of RTP to athlete age, lesion size, lesion location, position played, or round selected in the NFL draft. Players who underwent concomitant microfracture were 4.4 times less likely to return to the NFL than were those who did not undergo this procedure (95% CI, 1.3-15.5). Athletes who played more than 11.6 games per season were 4.7 times more likely to RTP than were those who played fewer games per season (95% CI, 1.4-16.6). Athletes who returned to play competed in 56 fewer games, 3.3 fewer seasons, and played in 3.2 fewer games per season compared with their level of competition before surgery. Conclusion: A majority (67%) of NFL players are able to RTP after arthroscopic knee surgery including chondroplasty of articular cartilage lesions. Athletes who play more games per season are more likely to RTP after chondroplasty of articular cartilage lesions of the knee, but those undergoing concomitant microfracture are less likely to return. No statistical significance was determined when comparing the athletes who returned to play with respect to age at surgery, lesion location, lesion size, lesion grade, position that the athlete played, or draft round.

Background: Pitching biomechanics are associated with performance and risk of injury in baseball. Previous studies have identified biomechanical differences between youth and adult pitchers but have not investigated changes within individual young pitchers as they mature. Hypothesis: Pitching kinematics and kinetics will change significantly during a youth pitcher’s career. Study Design: Descriptive laboratory study. Methods: Pitching biomechanics were captured in an indoor laboratory with a 12-camera, 240-Hz motion analysis system for 51 youth pitchers who were in their first season of organized baseball with pitching. Each participant was retested annually for the next 6 years or until he was no longer pitching. Thirty kinematic and kinetic parameters were computed and averaged for 10 fastballs thrown by each player. Data were statistically analyzed for the 35 participants who were tested at least 3 times. Within-participant changes for each kinematic and kinetic parameter were tested by use of a mixed linear model with random effects ( P < .05). Least squares means for sequential ages were compared via Tukey’s honestly significant difference test ( P < .05). Results: Three kinematic parameters that occur at the instant of foot contact—stride length, lead foot placement to the closed side, and trunk separation—increased with age. With age, shoulder external rotation at foot contact decreased while maximum shoulder external rotation increased. Shoulder and elbow forces and torques increased significantly with age. Year-to-year changes were most significant between 9 and 13 years of age for kinematics and between 13 and 15 years for normalized kinetics (ie, scaled by bodyweight and height). Conclusion: During their first few years, youth pitchers improve their kinematics. Elbow and shoulder kinetics increase with time, particularly after age 13. Thus, prepubescent pitchers may work with their coaches to improve the motions and flexibility of the players’ bodies and the paths of their arms. Once proper mechanics are developed, adolescent pitchers can focus more on improving strength and power.

Background: Baseball pitchers who undergo superior labrum anterior-posterior (SLAP) repair often have trouble returning to their previous level of performance. While the reason is often assumed to be diminished shoulder range of motion or other mechanical changes, differences in pitching biomechanics between baseball pitchers with a history of SLAP repair and pitchers with no injury history have not been studied previously. Hypothesis: The primary hypothesis was that compared with the control group, the SLAP group would exhibit compromised shoulder range of motion (external rotation and horizontal abduction) and internal rotation torque during pitching. Study Design: Controlled laboratory study. Methods: Pitching biomechanics were compared retrospectively between a group of 13 collegiate and professional pitchers with a history of a SLAP tear and a control group of 52 pitchers with no history of surgery; groups were matched by age, height, weight, and pitch velocity. Data were collected with an automated 3-dimensional motion analysis system while participants threw fastballs from the windup. Biomechanics of the shoulder (horizontal abduction and external rotation), elbow (flexion, extension velocity, and flexion torque), and body (stride length, shoulder horizontal adduction, and forward trunk tilt) were compared between the 2 groups. For each variable, a Student t test was used at an α level of .05. Results: Pitchers in the SLAP group exhibited significantly less shoulder horizontal abduction (10.0° ± 13.2° vs 21.0° ± 11.7°, respectively; P = .013) and shoulder external rotation (168.3° ± 12.7° vs 178.3° ± 7.3°, respectively; P = .016) than those in the control group. In addition, players in the SLAP group pitched with a more upright trunk, demonstrated by a less forward trunk tilt at the instant of ball release (30.2° ± 6.3° vs 34.4° ± 6.6°, respectively; P = .048). Conclusion: Pitchers with a history of SLAP repair produce less shoulder horizontal abduction, shoulder external rotation, and forward trunk tilt during pitching than do pitchers with no history of injury. Clinical Relevance: To facilitate normal pitching mechanics, shoulder external rotation and horizontal abduction at 90° should be primary objectives in surgical repair and rehabilitation after SLAP repair. In addition, pitchers should work with their pitching coaches to ensure proper forward trunk tilt.

Background: Lateral meniscal injury is a common and possibly career-threatening injury among players in the National Football League (NFL). The rate of return to play (RTP) and factors that affect RTP after lateral meniscal injury in NFL players are currently not defined. Purpose: The aims of this study were to determine the rate of RTP to regular-season NFL game play of NFL players after arthroscopic partial lateral meniscectomy and to identify factors that can predict the ability to return to play. Study Design: Case series; Level of evidence, 4. Methods: Seventy-two patients undergoing 77 arthroscopic lateral partial meniscectomies were followed to determine the rate of RTP (defined as successful RTP in at least 1 regular-season NFL game after meniscectomy) and factors predicting players’ ability to return to play. Perioperative variables were recorded using retrospective chart review. Players’ heights and weights, dates of return, draft rounds, and counts of games, starts, and seasons both before and after meniscectomy were all collected from statistical databases maintained by the NFL. Chi-square and Student t tests were performed to assess differences among covariates with respect to an athlete’s ability to return to play, and odds ratios were calculated as appropriate. All percentages were calculated as percent of total procedures performed (n = 77). Results: Of the 77 partial lateral meniscectomies performed, 61% (n = 47) resulted in the athlete returning to play at his previous level of competition with an average length of time to RTP of 8.5 months; 19 (40%) of those who returned were still active in the NFL at the time of follow-up. Age at time of surgery, games and seasons played before surgery, and individual position were not significantly different between those who did and did not return to play. Undergoing a concomitant procedure did not affect an athlete’s ability to return to play, nor did concurrent arthroscopic anterior cruciate ligament reconstruction affect a player’s likelihood to return to play. Players drafted in the first 4 rounds of the NFL draft were 3.7 times more likely to return to play than players drafted after the fourth round, and players who started more than 46.2% of their games played (the mean value for this population) were 2.8 times more likely to return to play. Speed-position players (running backs, receivers, linebackers, and defensive backs) were 4.0 times less likely to return to play than non–speed position players (linemen and tight ends). Conclusion: The majority of NFL players undergoing arthroscopic lateral meniscectomy are able to return to play. Players selected earlier in the NFL draft and who are listed as starters in more of their games are more likely to return to play, as are linemen and tight ends. It is significantly more difficult for running backs, receivers, linebackers, and defensive backs to return to play.

Controversy continues whether curveballs are stressful for young baseball pitchers. Furthermore, it is unproven whether professional baseball pitchers have fewer kinematic differences between fastballs and off-speed pitches than lower level pitchers. Kinematic and kinetic data were measured for 111 healthy baseball pitchers (26 youth, 21 high school, 20 collegiate, 26 minor league, and 18 major league level) throwing fastballs, curveballs, and change-ups in an indoor biomechanics laboratory with a high-speed, automated digitising system. Differences between pitch types and between competition levels were analysed with repeated measures ANOVA. Shoulder and elbow kinetics were greater in fastballs than in change-ups, while curveball kinetics were not different from the other two types of pitches. Kinematic angles at the instant of ball release varied between pitch types, while kinematic angles at the instant of lead foot contact varied between competition levels. There were no significant interactions between pitch type and competition level, meaning that kinetic and kinematic differences between pitch types did not vary by competition level. Like previous investigations, this study did not support the theory that curveballs are relatively more stressful for young pitchers. Although pitchers desire consistent kinematics, there were differences between pitch types, independent of competition level.

Swing trajectory and ground reaction forces (GRF) of 30 collegiate baseball batters hitting a pitched ball were compared between a standard bat, a bat with extra weight about its barrel, and a bat with extra weight in its handle. It was hypothesised that when compared to a standard bat, only a handle-weighted bat would produce equivalent bat kinematics. It was also hypothesised that hitters would not produce equivalent GRFs for each weighted bat, but would maintain equivalent timing when compared to a standard bat. Data were collected utilising a 500 Hz motion capture system and 1,000 Hz force plate system. Data between bats were considered equivalent when the 95% confidence interval of the difference was contained entirely within ±5% of the standard bat mean value. The handle-weighted bat had equivalent kinematics, whereas the barrel-weighted bat did not. Both weighted bats had equivalent peak GRF variables. Neither weighted bat maintained equivalence in the timing of bat kinematics and some peak GRFs. The ability to maintain swing kinematics with a handle-weighted bat may have implications for swing training and warm-up. However, altered timings of kinematics and kinetics require further research to understand the implications on returning to a conventionally weighted bat.

Objective Low-dose methotrexate (MTX) is an effective therapy for rheumatoid arthritis (RA), yet its mechanism of action is incompletely understood. The aim of this study was to explore the induction of apoptosis by MTX. Methods Flow cytometry was performed to assess changes in the levels of intracellular proteins, reactive oxygen species (ROS), and apoptosis. Quantitative polymerase chain reaction was performed to assess changes in the transcript levels of select target genes in response to MTX. Results MTX did not directly induce apoptosis but rather “primed” cells for markedly increased sensitivity to apoptosis via either mitochondrial or death receptor pathways, by a JNK-dependent mechanism. Increased sensitivity to apoptosis was mediated, at least in part, by MTX-dependent production of ROS, JNK activation, and JNK-dependent induction of genes whose protein products promote apoptosis. Supplementation with tetrahydrobiopterin blocked these MTX-induced effects. Patients with RA who were receiving low-dose MTX therapy expressed elevated levels of the JNK target gene, jun. Conclusion Our results support a model whereby MTX inhibits reduction of dihydrobiopterin to tetrahydrobiopterin, resulting in increased production of ROS, increased JNK activity, and increased sensitivity to apoptosis. The finding of increased jun levels in patients with RA receiving low-dose MTX supports the notion that this pathway is activated by MTX in vivo and may contribute to the efficacy of MTX in inflammatory disease.

A rectus abdominis-adductor longus (RA-AL) aponeurotic plate injury, commonly associated with athletic pubalgia, sports hernia, or a core muscle injury, causes significant dysfunction in athletes. Increased recognition of this specific injury distinct from inguinal hernia abnormalities has led to better management of this debilitating condition.Surgical repair of RA-AL aponeurotic plate injuries will result in decreased symptoms and high rates of return to play.Case series; Level of evidence, 4.Using our billing and clinical database, patients who underwent RA-AL aponeurotic plate repair by a single surgeon at a single institution were contacted for Hip Outcome Score (HOS) and return-to-play data. Patients with a confirmed diagnosis by history, physical examination, and magnetic resonance imaging who failed 6 to 12 weeks of appropriate conservative treatment were indicated for surgery. Surgical repair involved adductor longus fractional lengthening, limited adductor longus tenotomy, and a turn-up flap of the released adductor tendon and aponeurosis onto the rectus abdominis for imbrication reinforcement.Of 100 patients who met the inclusion criteria, 85 (85%) were contacted. A total of 82 (96%) patients were able to return to play at a mean of 4.1 months after repair. Hip function was rated as 98% of normal and sports function as 92% of normal. Factors associated with negative outcomes were multiple procedures, prior inguinal hernia repair, and female sex. Negative outcomes were demonstrated by decreased HOS scores and decreased sports function. The overall complication rate was 7%.RA-AL aponeurotic plate repair by the method of an adductor-to-rectus abdominis turn-up flap is a safe procedure with high return-to-play success. Patients who had previously undergone inguinal hernia repair or other hip/pelvic-related surgery and female patients had worse outcomes.

Gamma-ray bursts (GRBs) are the most powerful explosions known in the universe. Sensitive measurements of the high-energy spectra of GRBs can place important constraints on the burst environments and radiation processes. Until recently, there were no observations during the first few minutes of GRB afterglows in the energy range between 30 GeV and ~1 TeV. With the launch of the Swift GRB Explorer in late 2004, GRB alerts and localizations within seconds of the bursts became available. The Solar Tower Atmospheric Cherenkov Effect Experiment (STACEE) was a ground-based, gamma-ray telescope with an energy threshold of ~150 GeV for sources at zenith. At the time of Swift's launch, STACEE was in a rare position to provide >150 GeV follow-up observations of GRBs as fast as three minutes after the burst alert. In addition, STACEE performed follow-up observations of several GRBs that were localized by the HETE-2 and INTEGRAL satellites. Between 2002 June and 2007 July, STACEE made follow-up observations of 23 GRBs. Upper limits are placed on the high-energy gamma-ray fluxes from 21 of these bursts.

Objectives: There has been a renewed interest in UCL repair in overhead athletes. This is largely due to greater understanding of UCL pathology, improvement in fixation technology and the extensive rehab required to return from UCL reconstruction. Initial data regarding UCL repair in overhead athletes was poor and therefore UCL repair was largely abandoned in favor of reconstruction. However, recent literature examining UCL repair with anchor only fixation demonstrated an excellent rate of return to play, reduced time to return to play and a low complication rate. Based on this promising data, we have developed a novel technique of UCL repair with internal brace augmentation that we have used in overhead throwing athletes. We performed a prospective study evaluating the outcomes of this procedure with respect to return to play, time to return to play, functional outcome score and complications. Methods: Overhead athletes undergoing UCL repair with internal brace augmentation were prospectively followed for a minimum of one year. Patients were carefully selected from those who would traditionally be considered for UCL reconstruction. Initially, patients were considered if they had an avulsion of the UCL with otherwise healthy UCL tissue and had a vested interest in shortened rehab. As the study progressed, interest in shortened rehab became a less stringent criteria. Demographic and operative data were collected at the time surgery. This data was compiled for both desciption and comparison between subgroups. Patients were then contacted 1 year postoperatively and assessed for return to play, time to return to play and KJOC scores. Complications were documented and patients having complications were detailed. Results: 66 overhead athletes underwent UCL repair with internal brace augmentation during the study period. 8 were lost to follow up, leaving 58 athletes included in the study. Average age at the time of surgery was 17.9 years old. There were 43 baseball pitchers, 8 baseball position players, 4 softball players, 2 football quaterbacks, and 1 javelin thrower. 96% (54/56) of those who desired to return to the same or higher level of competition were able to do so at an average time of 6.1 months (range 3.2-12 months). 65% of these were able to return in less than 6 months. Many of those who took longer than 6 months did so due to timing within the season. Average KJOC score was 90.2 at 1-year follow-up. 3 patients required return to the operating room, 2 of which were eventually able to return to their previous level of play. There was 1 late failure over 3 years from the index procedure. Comparative subgroup data is presented in table 1. Conclusion: UCL repair with internal brace augmentation is a viable option for overhead throwers with selected UCL pathology who wish to return to sport in a shorter time frame than allowed by traditional UCL reconstruction. Comparative Analysis of Subgroups. Time to return to N KJOC P-value play (Months) P-value Location of tear Distal 34 89.6 6.00 Proximal 24 90.6 P=0.71 6.19 P=0.74 Severity of tear Partial 35 89.5 6.14 Complete 23 91.4 P=0.51 6.08 P=0.86 Ulnar Nerve Transposition UNT performed 32 90.9 6.40 UNT not performed 26 89.4 P=0.17 5.75 P=0.16 Overall 58 90.2 6.13

We report on observations of very high energy gamma rays from the shell-type supernova remnant (SNR) Cassiopeia A with the Very Energetic Radiation Imaging Telescope Array System stereoscopic array of four imaging atmospheric Cherenkov telescopes in Arizona. The total exposure time for these observations is 22 hr, accumulated between September and November of 2007. The gamma-ray source associated with the SNR Cassiopeia A was detected above 200 GeV with a statistical significance of 8.3 sigma. The estimated integral flux for this gamma-ray source is about 3% of the Crab-Nebula flux. The photon spectrum is compatible with a power law dN/dE proportional to E(-Gamma) with an index Gamma = 2.61 +/- 0.24(stat) +/- 0.2(sys). The data are consistent with a point-like source. We provide a detailed description of the analysis results and discuss physical mechanisms that may be responsible for the observed gamma-ray emission.

We present the result of a search of the Milagro sky map for spatial correlations with sources from a subset of the recent Fermi Bright Source List (BSL). The BSL consists of the 205 most significant sources detected above 100 MeV by the Fermi Large Area Telescope. We select sources based on their categorization in the BSL, taking all confirmed or possible Galactic sources in the field of view of Milagro. Of the 34 Fermi sources selected, 14 are observed by Milagro at a significance of 3 standard deviations or more. We conduct this search with a new analysis which employs newly-optimized gamma-hadron separation and utilizes the full 8-year Milagro dataset. Milagro is sensitive to gamma rays with energy from 1 to 100 TeV with a peak sensitivity from 10-50 TeV depending on the source spectrum and declination. These results extend the observation of these sources far above the Fermi energy band. With the new analysis and additional data, multi-TeV emission is definitively observed associated with the Fermi pulsar, J2229.0+6114, in the Boomerang Pulsar Wind Nebula (PWN). Furthermore, an extended region of multi-TeV emission is associated with the Fermi pulsar, J0634.0+1745, the Geminga pulsar., Comment: Accepted for publication in Astrophysical Journal Letters June 30, 2009

Results are presented of a harmonic analysis of the large scale cosmic-ray anisotropy as observed by the Milagro observatory. We show a two-dimensional display of the sidereal anisotropy pro jections in right ascension generated by the fitting of three harmonics to 18 separate declination bands. The Milagro observatory is a water Cherenkov detector located in the Jemez mountains near Los Alamos, New Mexico. With a high duty cycle and large field-of-view, Milagro is an excellent instrument for measuring this anisotropy with high sensitivity at TeV energies. The analysis is conducted using a seven year data sample consisting of more than 95 billion events, the largest such data set in existence. We observe an anisotropy with a magnitude around 0.1% for cosmic rays with a median energy of 6 TeV. The dominant feature is a deficit region of depth (2.49 +/- 0.02 stat. +/- 0.09 sys.)x10^(-3) in the direction of the Galactic North Pole centered at 189 degrees right ascension. We observe a steady increase in the magnitude of the signal over seven years., Comment: 36 pages, 16 figures, submitted to ApJ

We present evidence that the very high energy (VHE, E > 100 GeV) gamma-ray emission coincident with the supernova remnant IC 443 is extended. IC 443 contains one of the best studied sites of supernova remnant/molecular cloud interaction and the pulsar wind nebula CXOU J061705.3+222127, both of which are important targets for VHE observations. VERITAS observed IC 443 for 37.9 hr during 2007 and detected emission above 300 GeV with an excess of 247 events, resulting in a significance of 8.3 standard deviations (sigma) before trials and 7.5 sigma after trials in a point-source search. The emission is centered at 6(h)16(m)51(s)+22 degrees 30'11 '' (J2000)+/- 0 degrees.03(stat)+/- 0 degrees.08(sys), with an intrinsic extension of 0 degrees.16 +/- 0 degrees.03(stat)+/- 0 degrees.04(sys). The VHE spectrum is well fit by a power law (dN/dE = N(0) x(E/TeV)(-Gamma)) with a photon index of 2.99 +/- 0.38(stat)+/- 0.3(sys) and an integral flux above 300 GeV of (4.63 +/- 0.90(stat)+/- 0.93(sys)) x 10(-12) cm(-2) s(-1). These results are discussed in the context of existing models for gamma-ray production in IC 443.

The astrophysical journal / 2 815(2), L22 -(2015). doi:10.1088/2041-8205/815/2/L22, Outbursts from gamma-ray quasars provide insights on the relativistic jets of active galactic nuclei and constraints on the diffuse radiation fields that fill the universe. The detection of significant emission above 100 GeV from a distant quasar would show that some of the radiated gamma-rays escape pair-production interactions with low-energy photons, be it the extragalactic background light (EBL), or the radiation near the supermassive black hole lying at the jet's base. VERITAS detected gamma-ray emission up to ~200 GeV from PKS 1441+25 (z = 0.939) during 2015 April, a period of high activity across all wavelengths. This observation of PKS 1441+25 suggests that the emission region is located thousands of Schwarzschild radii away from the black hole. The gamma-ray detection also sets a stringent upper limit on the near-ultraviolet to near-infrared EBL intensity, suggesting that galaxy surveys have resolved most, if not all, of the sources of the EBL at these wavelengths., Published by Institute of Physics Publ., London

Background: While the high rate of ulnar collateral ligament (UCL) injuries in professional baseball is widely discussed in the media and medical literature, the actual prevalence of UCL reconstruction has not been documented. Hypothesis: The prevalence of UCL reconstruction will be higher among pitchers than nonpitchers, and Major League Baseball (MLB) pitchers will have a higher prevalence than will minor league pitchers. Study Design: Descriptive epidemiology study. Methods: An online questionnaire was distributed to all 30 MLB organizations. Certified athletic trainers from each team administered the questionnaire to all players in the organization, including major league players and 6 levels of minor league players. Demographic data were compared between major and minor league players. Continuous variables (age, years of professional baseball, country of origin, etc) were compared with Student t tests ( P < .05). Categorical variables (level, position, etc) were compared using chi-square analysis ( P < .05). Results: A total of 5088 professional baseball players (722 major league and 4366 minor league) participated in the survey. Pitchers represented 53% of all players, and 497 players reported at least 1 UCL reconstruction, demonstrating a prevalence rate of 10% (497 of 5088). Pitchers reported a significantly higher prevalence of UCL reconstruction (16%; 437 of 2706) than nonpitchers (3%; 60 of 2382; P < .001). Among major league pitchers, 25% (96 of 382) had a history of UCL reconstruction, while minor league pitchers showed a 15% (341 of 2324) prevalence ( P < .001). Major league pitchers were also significantly older (28.8 ± 3.9 years) than minor league pitchers (22.8 ± 3.0; P < .001). The majority of major leaguers (86%) had their UCL reconstruction as professional pitchers, whereas the majority of minor league pitchers (61%) underwent their UCL reconstruction during high school and college ( P < .001). The rates of UCL revision, prior elbow surgery, prior shoulder surgery, and types of UCL graft were similar between the major league and minor league pitchers. No difference in prevalence was shown between pitchers born in the United States versus Latin American countries. Conclusion: Pitchers have a high prevalence of UCL reconstruction in professional baseball, with 25% of major league pitchers and 15% of minor league pitchers having a history of the surgery.

Background: A relatively high number of active professional baseball pitchers have a history of ulnar collateral ligament reconstruction (UCLr) on their throwing elbow. Controversy exists in the literature about whether professional baseball pitchers regain optimal performance after return from UCLr. It has been suggested that pitchers may have different biomechanics after UCLr, but this has not been previously tested. Hypothesis: It was hypothesized that, compared with a control group without a history of UCLr, professional pitchers with a history of UCLr would have (1) significantly different throwing elbow and shoulder biomechanics; (2) a shortened stride, insufficient trunk forward tilt, and excessive shoulder horizontal adduction, characteristics associated with “holding back” or being tentative; (3) late shoulder rotation; and (4) improper shoulder abduction and trunk lateral tilt. Study Design: Controlled laboratory study. Methods: A total of 80 active minor league baseball pitchers (and their 8 Major League Baseball organizations) agreed to participate in this study. Participants included 40 pitchers with a history of UCLr and a matched control group of 40 pitchers with no history of elbow or shoulder surgery. Passive ranges of motion were measured for each pitcher’s elbows and shoulders, and then 23 reflective markers were attached to his body. The pitcher took as many warm-up pitches as desired and then threw 10 full-effort fastballs for data collection. Ball speed was recorded with a radar gun. The reflective markers were tracked with a 10-camera, 240-Hz automated motion analysis system. Eleven biomechanical parameters were computed for each pitch and then averaged for each participant. Demographic, range of motion, and biomechanical parameters were compared between the UCLr group and the control group by use of Student t tests (significance set at P < .05). Results: All hypotheses were rejected, as there were no differences in pitching biomechanics between the UCLr group and the control group. There were also no differences in passive range of motion between the 2 groups. Conclusion: Compared with a control group, active professional pitchers with a history of UCLr displayed no significant differences in shoulder and elbow passive range of motion and no significant differences in elbow and shoulder biomechanics. Clinical Relevance: Clinical studies have previously shown that 10% to 33% of professional pitchers do not return to their preinjury level; however, the current study showed that those pitchers who successfully return to professional baseball after UCLr pitch with biomechanics similar to that of noninjured professionals.

The CERN Axion Solar Telescope (CAST), a 10 meter long LHC, 9 Tesla, test magnet is mounted on a moving platform that tracks the sun about 1.5 hours during sunrise, again during sunset. It moves ±8 0 vertically and ±40 0 horizontally. It has been taking data continuously since July 10, 2003. Data analyzed thus far yield an upper bound on the photon-axion coupling constant, g aγγ ⩽ 3 × 10 −10 GeV −1 for axion masses less than 5 × 10 −2 eV.

We present results from VERITAS observations of the BL Lac object PG 1553+113 spanning the years 2010, 2011, and 2012. The time-averaged spectrum, measured between 160 and 560\,GeV, is well described by a power law with a spectral index of $4.33 \pm 0.09$. The time-averaged integral flux above $200\,$GeV measured for this period was $(1.69 \pm 0.06) \times 10^{-11} \, \mathrm{ph} \, \mathrm{cm}^{-2} \, \mathrm{s}^{-1}$, corresponding to 6.9\% of the Crab Nebula flux. We also present the combined $\gamma$-ray spectrum from the Fermi Large Area Telescope and VERITAS covering an energy range from 100~MeV to 560~GeV. The data are well fit by a power law with an exponential cutoff at $\rm {101.9 \pm 3.2 \, \mathrm{GeV}} $. The origin of the cutoff could be intrinsic to PG~1553+113 or be due to the $\gamma$-ray opacity of our universe through pair production off the extragalactic background light (EBL). Given lower limits to the redshift of $\rm z \negthinspace > \negthinspace 0.395$ based on optical/UV observations of PG~1553+113, the cutoff would be dominated by EBL absorption. Conversely, the small statistical uncertainties of the VERITAS energy spectrum have allowed us to provide a robust upper limit on the redshift of PG 1553+113 of $z \negthinspace \leq \negthinspace 0.62$. A strongly-elevated mean flux of $(2.50 \pm 0.14) \times 10^{-11} \, \mathrm{ph} \, \mathrm{cm}^{-2} \, \mathrm{s}^{-1}$ (10.3\% of the Crab Nebula flux) was observed during 2012, with the daily flux reaching as high as $(4.44 \pm 0.71) \times 10^{-11} \, \mathrm{ph} \, \mathrm{cm}^{-2} \, \mathrm{s}^{-1}$ (18.3\% of the Crab Nebula flux) on MJD 56048. The light curve measured during the 2012 observing season is marginally inconsistent with a steady flux, giving a $\chi^2$ probability for a steady flux of 0.03\%., Comment: in press in ApJ, 2014

Prompt emission from the very fluent and nearby (z=0.34) gamma-ray burst GRB 130427A was detected by several orbiting telescopes and by ground-based, wide-field-of-view optical transient monitors. Apart from the intensity and proximity of this GRB, it is exceptional due to the extremely long-lived high-energy (100 MeV to 100 GeV) gamma-ray emission, which was detected by the Large Area Telescope on the Fermi Gamma-ray Space Telescope for ~70 ks after the initial burst. The persistent, hard-spectrum, high-energy emission suggests that the highest-energy gamma rays may have been produced via synchrotron self-Compton processes though there is also evidence that the high-energy emission may instead be an extension of the synchrotron spectrum. VERITAS, a ground-based imaging atmospheric Cherenkov telescope array, began follow-up observations of GRB 130427A ~71 ks (~20 hr) after the onset of the burst. The GRB was not detected with VERITAS; however, the high elevation of the observations, coupled with the low redshift of the GRB, make VERITAS a very sensitive probe of the emission from GRB 130427A for E > 100 GeV. The non-detection and consequent upper limit derived place constraints on the synchrotron self-Compton model of high-energy gamma-ray emission from this burst., 22 pages, 4 figures, 1 table

Objectives: Shoulder instability is a common and limiting injury to football players. The return to play (RTP) percentage and factors affecting RTP after shoulder stabilization in National Football League (NFL) players are not defined. The purpose of this study was to determine the rate of return to professional football play in the NFL after shoulder stabilization and to determine what factors may affect RTP in these athletes. Methods: Sixty NFL players who had undergone shoulder stabilization at our institution were followed to determine the rate of RTP and factors predicting RTP. Chart review was performed to glean perioperative data and follow-up was performed by accessing the statistics database maintained by the NFL. Successful RTP was defined as return to play in at least one regular season NFL game following surgery. Chi square and Student’s t-tests were performed to examine differences between perioperative and athletic history variables and a player’s ability to RTP. Results: Ninety percent (54 of 60) of NFL players were able to return to game play following shoulder stabilization. The average time to RTP was 8.6 months. Age, number of games before surgery, and career length were not statistically different between those that returned and those that did not. Eleven of the sixty patients underwent open stabilization. Ninety-two percent (45/49) of the arthroscopically treated and eighty-two percent (9/11) of the openly treated athletes were able to RTP; these rates were not found to be significantly different. Playing history and demographics were similar between the open and arthroscopic groups. Players selected before the fourth round of the NFL draft were 7.6 times more likely to RTP. Circumferential labral tears were found in seven athletes, all of whom were able to RTP following surgery. Conclusion: The RTP rates for NFL players following shoulder stabilization are quite high (90%). There is no difference in RTP rates between open and arthroscopic repairs. Being selected in the first four rounds of the NFL draft is highly predictive of a player’s ability to RTP.

Background: Injuries to the elbow joint in baseball pitchers appear common. There appears to be a correlation between shoulder range of motion and elbow injuries. Purpose: To prospectively determine whether decreased ROM of the throwing shoulder is correlated with the onset of elbow injuries in professional baseball pitchers. Study Design: Cohort study; Level of evidence, 2. Methods: For 8 consecutive years (2005-2012), passive range of motion of both the throwing and nonthrowing shoulders of all major and minor league pitchers within a single professional baseball organization were measured by using a bubble goniometer during spring training. In total, 505 examinations were conducted on 296 pitchers. Glenohumeral external rotation and internal rotation were assessed in the supine position with the arm at 90° of abduction and in the plane of the scapula. The scapula was stabilized per methods previously established. Total rotation was defined as the sum of external rotation and internal rotation. Passive shoulder flexion was assessed with the subject supine and the scapula stabilized per methods previously established. Elbow injuries and days missed because of elbow injuries were assessed and recorded by the medical staff of the team. Throwing and nonthrowing shoulder measurements were compared by using Student t tests; 1-tailed Fisher exact tests were performed to identify significant associations between shoulder motion and elbow injury. Nominal logistic regression was performed to determine the odds of elbow injury. Results: Significant differences were noted during side-to-side comparisons within subjects. There were 49 elbow injuries and 8 surgeries in 38 players, accounting for a total of 2551 days missed. Neither glenohumeral internal rotation deficit nor external rotation insufficiency was correlated with elbow injuries. Pitchers with deficits of >5° in total rotation in their throwing shoulders had a 2.6 times greater risk for injury. Pitchers with deficit of ≥5° in flexion of the throwing shoulder had a 2.8 times greater risk for injury. Conclusion: Bilateral differences in shoulder total rotation and flexion had a significant effect on the risk for elbow injuries in pitchers. Clinicians need to be aware of these findings and plan preventive programs that address these issues in hopes of reducing elbow injuries.

This paper reports the results from three targeted searches of Milagro TeV sky maps: two extragalactic point source lists and one pulsar source list. The first extragalactic candidate list consists of 709 candidates selected from the Fermi-LAT 2FGL catalog. The second extragalactic candidate list contains 31 candidates selected from the TeVCat source catalog that have been detected by imaging atmospheric Cherenkov telescopes (IACTs). In both extragalactic candidate lists Mkn 421 was the only source detected by Milagro. This paper presents the Milagro TeV flux for Mkn 421 and flux limits for the brighter Fermi-LAT extragalactic sources and for all TeVCat candidates. The pulsar list extends a previously published Milagro targeted search for Galactic sources. With the 32 new gamma-ray pulsars identified in 2FGL, the number of pulsars that are studied by both Fermi-LAT and Milagro is increased to 52. In this sample, we find that the probability of Milagro detecting a TeV emission coincident with a pulsar increases with the GeV flux observed by the Fermi-LAT in the energy range from 0.1 GeV to 100 GeV., Comment: 18 pages, 6 Figures and 4 tables