HISTORY: A 10-year-old Female w/o past medical history was brought to the ED by her mother due to left leg pain and swelling. The mother states that the patient practices taekwondo. 3 days before during training, she sustained a direct kick over the left thigh. The patient states that since then she has been having pain. Mother has been doing supportive care at home including ice, Epsom salt compresses, and Arnica. The mother states that despite the pain, the patient continued training. The mother states that the pain and swelling have markedly increased over the left thigh and knee, which started to impair ambulation with associated excruciating pain on palpation. The patient was taken to urgent care where X Rays ruled out a fracture. The patient was seen in the ED due to the worsening of swelling and pain. ROS was negative except for hpi. PHYSICAL EXAMINATION: Left lower extremity swelling from thigh to knee, tender to palpation in the lateral aspect over the quadriceps even with light touch. The patient was not able to bear weight or ambulate due to pain. peripheral pulses preserved. Skin is Normal color, warm, No bruise over the thigh. Neuro: grossly intact, motor/sensation. DIFFERENTIAL DIAGNOSIS: Quadriceps hematoma, Quadriceps strain, Quadriceps rupture, Compartment syndrome. TEST AND RESULTS: MRI LT femur w/o con: Severe sprain of the vastus intermedius muscle with partial tearing of the mid to distal aspect of the muscle lateral of midline associated with a large hematoma and intramuscular hemorrhage and edema. Mild straightening of the vastus medialis muscle proximally. FINAL WORKING DIAGNOSIS: Vastus intermedius rupture. TREATMENT AND OUTCOMES: RICE therapy, ACE wrap a few hours a day, Stretching exercises, Cryotherapy, Relative rest, cupping, acupuncture, and laser therapy. The Patient was pain-free and no longer needed crutches after a month. The patient started light level tournaments and after more than a month in recovery, she won a taekwondo National Championship.

HISTORY: A 51-year-old male marathon runner presented with pleuritic chest pain and increasingly progressive shortness of breath at the end of his runs. At baseline, he was running a marathon in 3 hours, but his runs were reduced to less than 15 miles. He completed a 15k in 1 hour and 30 minutes but with severe dyspnea on exertion. Patient was referred to the Sports medicine clinic for further evaluation. PHYSICAL EXAMINATION: Vitals within normal limits NAD, speaking in full sentences, no chest wall tenderness. CV: regular rate and rhythm. no edema. Pulmonary: normal respiratory effort without distress, absent of wheezes or rales. DIFFERENTIAL DIAGNOSIS: 1) Overtraining syndrome 2) Asthma/Exercise induced bronchospasm 3) Viral syndrome 4) Pulmonary embolism TESTS AND RESULTS: 8/2017: EKG nonspecific/chest X-ray reported small bilateral pleural effusion 8/2017: Non contrast chest CT - no pleural effusion 8/2017: TTEcho: EF 60-65%, unremarkable valves & chambers 8/2017: Treadmill test unspecific, high exercise tolerance 9/2017: CXR - persistence of bilateral pleural effusion. 1/2018: Myocardial perfusion scan - no evidence of stress induced ischemia 3/2018: Spirometry - normal, no response to Bronchodilators. 3/2018: Non Contrast chest CT - Diminished right lung pleural opacity, probably represented inflammatory change 9/2018: D-dimer 564 9/2018: CT-A - small embolus in a subsegmental branch of the pulmonary artery to the left lower lobe. Second pulmonary embolus in a segmental branch of the pulmonary artery to the right lower lobe. FINAL/WORKING DIAGNOSIS Bilateral unprovoked pulmonary embolism TREATMENT AND OUTCOMES 1) Discussed indications, risks, benefits, and dietary & activity precautions of anticoagulation with Warfarin vs. Direct Oral Anticoagulant such as Pradaxa with patient in extensive detail. Patient opted for Pradaxa. 2) Hypercoagulable work-up sent and hematology referral

HISTORY: An experienced 39-year-old male ultraendurance runner started experiencing shortness of breath, coughing and inspiratory difficulties 80km into the 170km Ultra-Trail du Mont Blanc. He was able to finish the race by reducing his exercise intensity and was examined ~2 hours after crossing the finish line. PHYSICAL EXAMINATION: The runner appeared weak, pale, with breathing shallow and constrained and oxygen saturation reduced from 97 to 92%. Resting respiratory rate and heart rate were elevated pre vs. post-race at 15 vs. 8 breaths and 52 vs. 103 beats per minute respectively. Lung auscultation found diffuse crackling in both lungs, but no wheezing. DIFFERENTIAL DIAGNOSIS: 1. Exercise-induced asthma/bronchoconstriction 2. Pulmonary edema TEST RESULTS: Pulmonary function testing: FVC and FEV1 dropped 3L from baseline, with coughing making PFTs difficult Lung Diffusion: DLCO dropped 25%, higher than the 13-16% range seen in other racers Alveolar-capillary membrane conductance (Dm) fell 50%, this was not observed in other racers Pulmonary capillary blood volume (Vc) dropped 28% from baseline, this was typical of the group Resting Echocardiography: Post-race stroke volume was reduced, but cardiac output remained elevated compared to baseline (SV: 70 vs. 56mL; Q: 3.9 vs. 4.8L/min) RV diastolic area and RA area both increased post-race and RV function was reduced (RV area: 22.7 vs. 26.1 cm; RA area: 16.7 vs. 19.6 cm; RV FAC: 37.9 vs. 30.7%) Blood work: 38-fold increase in CK-MB (3.7 to 142.7 pg/mL) 8-fold increase in cTnI (0.00 to 0.08 ng/mL) 4-fold increase in BNP (15 to 64 pg/mL) FINAL /WORKING DIAGNOSIS: Runner exhibited evidence of acute injury to the heart and skeletal muscle. The race, which was characterized by intermittent altitude exposure, likely induced a substantial pressure-volume overload. Further, the reduction in pulmonary function and lung diffusion with the unique reduction in Dm, along with desaturation and lung sounds suggested mild pulmonary edema. TREATMENT AND OUTCOMES: 1. Rest 2. Within 24 hours, everything was recovering: saturation returning to 97%, PFT close to predicted and lung diffusion improving, but not back to baseline 3. Runner reported it taking about a week for his lungs to feel normal again 4. He has returned to training at normal intensity

Reviewed by: Disagreement by Bryan Frances James Pearson (bio) Disagreement. By Bryan Frances. Cambridge: Polity Press, 2014. Pp. x + 214. Paper $22.95, isbn 978-0-7456-7227-4. Attention to the question of whether testimony is a distinctive source of knowledge is a comparatively recent development in Western epistemology. Does being told that p constitute reason for you to believe that p, independently of what you empirically establish about the speaker’s reliability, sincerity, and evaluative position? Still more recently — in just the last decade — Western epistemologists have become occupied with related problems concerning disagreement. What is the rational response, for instance, to discovering that an epistemic peer disagrees with you about p? In the battery of new articles that explore this question, various fine-grained distinctions have been proposed to accommodate cases where it seems that disagreement ought to shake our confidence that p and cases where we appear entitled to remain steadfast. Inevitably, there has been some overlap and redundancy between these rapid-fire proposals. An unfortunate consequence of the shifting structure of our burgeoning terminological framework is that disagreement is a difficult topic to teach effectively. Confronted with the proliferation of fascinating but increasingly esoteric test cases in recent articles, students often find it difficult to see the forest for the trees. This is a shame, as the topic is fresh, practically relevant, and packed with the potential to excite undergraduates. Bryan Frances’ accessible textbook is therefore a welcome addition to the literature. Disagreement is exceptionally well paced, introducing material over twenty-eight short and engaging chapters. The fifty-five problem cases (or “stories” [pp. ix–x]) that Frances provides are carefully explained and sequenced, allowing students to gradually refine their understanding of the need for terminological subtlety. By inviting readers to puzzle over his stories, and by both admitting that his own views have changed and pointing out where his current position is tentative, Frances successfully conveys the youth of this branch of Western epistemology. Readers are made to feel that their own innovations could advance philosophical understanding of this topic, which would be a great motivation in the classroom. Instead of critiquing views defended in the current literature, many of which he finds “premature” (p. 6), Frances uses his stories to guide readers through the central ideas underlying contemporary debates. Throughout, he emphasizes the practical question of what philosophy can teach us about everyday disagreements, even going so far as to lay out a decision procedure for how to resolve them (p. 110). This approach allows him to touch on many of the issues that undergraduates find most interesting, although I found it disappointing that he omits discussion of intrapersonal disagreement. (My students have enjoyed reflecting upon the rationality of their [End Page 357] own changes of mind, and when they should have trusted their initial judgment.) Similarly, although he writes that the “ethics of disagreement” is beyond the scope of his book, he misses the opportunity provided by his approach to relate epistemology to political theory (p. 76). A chapter examining the link between disagreement and collective agency (how should a group whose members disagree decide to act?) would also have been appreciated. Nevertheless, Frances expertly forestalls a number of journeys down blind alleys that, in my experience, students are apt to tread when first confronted with this material. Of particular note in this respect are Frances’ distinction between how we typically behave when faced with disagreement (when splitting a dinner check, for example, we may amicably accept our friend’s calculation rather than quibble over a few dollars) and what the standards of rationality require of us in such situations (p. 75); his surfacing of key “disagreement factors,” such as the background knowledge and cognitive ability of disputants, which often ground intuitions about how seriously we ought to take particular disagreements (p. 26); his contrast between the rationality of retaining one’s belief in a case of disagreement and the rationality of one’s retained belief, and his subsequent explanation of their independence (p. 80); his attention to the differing demands of disagreements between solitary disputants and groups of disputants (pp. 94–98); and, perhaps most of all, his characterization of disagreement...

Skin protection measures - barrier creams, protective gloves - and skin care are widely recommended for the prevention of occupational hand dermatitis (HD) in skin risk professions, but there is hardly anything known about uptake levels of the measures. The objective of this controlled intervention study was to quantify the uptake and maintenance of skin protection and skin care measures in first-year bakers' apprentices. A total of 94 first-year bakers' apprentices were included in the study in September 2000. The apprentices were assigned to the skin protection and control group class-wise to reduce contamination. The skin protection group comprised 39 apprentices who were trained in skin protection measures at the beginning and after 4 weeks of training. 55 apprentices were assigned to the control group representing no skin protection intervention. Standardized interviews took place at the beginning of the training and at 4 monthly follow-ups (FU). The uptake of skin protection measures differed significantly between the groups (barrier cream p < 0.0001, protective gloves p = 0.046, skin care p = 0.025). Barrier cream use in the skin protection group was incorporated in the daily routine very well from the start and reached 100% at the end of the examination period (4th FU). At this time, only 3.2% of the controls used barrier creams. The level of acceptance of protective gloves (4th FU: skin protection group 43.3%; controls 32.3%) was considerably lower than that of barrier creams. The initial level of regular skin care was high in both groups (skin protection group 67.6%, controls 61.7%). After the intervention the acceptance of skin care rose to 88.9% in the skin protection group compared to 68.1% in the controls (4th FU). The present study has shown that skin protection and skin care measures can be introduced successfully in the daily routine of a skin risk occupation and high uptake and maintenance rates can be achieved.

Objective. The objective of this controlled intervention study was to quantify the efficacy of skin protection (SP) measures and ultraviolet B (UVB) hardening in the prevention of hand dermatitis in bakers' apprentices. Method. SP measures were compared against UVB hardening in a controlled clinical trial of 94 apprentices. The apprentices were assigned to the intervention arms class-wise. Bakers' apprentices involved in a previous follow-up study served as additional controls representing no intervention. The apprentices were interviewed and examined in a standardised way at the beginning of the training and at 4 monthly follow-ups. Transepidermal water loss (TEWL) was measured at the back of the hands. Results. Demographic profile and atopy criteria were equally distributed in the two intervention arms and the control group. Point prevalence of hand dermatitis after 6 months was highest in the controls (29.1%) followed by the UVB (19.4%) and the SP group (13.3%). UVB hardening and SP measures reduced hand dermatitis prevalence by 9.7% (95%CI: –8.5 to 28.1) and 15.7% (95%CI: –2.4 to 33.9), respectively. Application of SP measures reduced the odds ratios (ORs) for hand dermatitis 0.8-fold (95%CI: 0.17–3.70) and 0.33-fold (95%CI: 0.09–1.23) compared with the UVB group and the controls, respectively. These clinical trends were confirmed by statistically significant differences in TEWL values. TEWL values were consistently higher in the UVB group than in the SP group ( P =0.002). Conclusions. This study provided evidence, based on significant differences in TEWL levels, that general SP measures may be more effective than UV light hardening of the skin, which in turn was more effective than no intervention. This trend was supported by the frequency of development of clinical hand dermatitis, although differences did not reach statistical significance. A multi-centre trial is recommended to confirm the efficacy of SP measures in a larger randomised study.