Indian River Lagoon surface water improvement and management (SWIM) plan, 2002 update.

In recognition of the need to place additional emphasis on the restoration, protection, and management of the surface water resources of the state, the Florida Legislature, through the Surface Water Improvement and Management (SWIM) Act of 1987, directed the state’s water management districts to “design and implement plans and programs for the improvement and management of surface water” (Section 373.451, Florida Statutes [FS]). The SWIM legislation requires the water management districts to protect the ecological, aesthetic, recreational, and economic value of the state’s surface water bodies, keeping in mind that water quality degradation is frequently caused by point and nonpoint source pollution and that degraded water quality can cause both direct and indirect losses of aquatic habitats. This 2002 update is the second update of the Indian River Lagoon SWIM Plan. This 2002 plan update includes a status report on the state of the Lagoon, a summary of progress on projects undertaken since the last update, and recommendations for future projects and other actions over the next 5 years. (262pp.

Dermatomyositis as Paraneoplastic Manifestation of Tonsillar Squamous Cell Carcinoma

OBJECTIVE: Discussion of a rare case of dermatomyositis associated with tonsillar neoplasm in an African American woman. BACKGROUND: Dermatomyositis is a syndrome of inflamatory myopathy with multiorgan manifestations which has been linked to immune dysregulation and neoplasia. INTRODUCTION: Many studies have shown five to seven fold increased risk of developing malignancy with dermatomyositis within two years of presentation. Most common cancers reported are adenocarcinomas of lung, breast, ovaries, stomach, pancreas and bladder. Dermatomyositis as a paraneoplastic manifestation of tonsillar squamous cell carcinoma has not previously been described. DESIGN: This is a case report of a 52 year old woman who presented for the evaluation of weakness, facial rash and burning pains. Diagnosis of dermatomyositis was made clinically and corroborated by EMG and muscle biopsy. She was started on prednisone but did not improve. CT chest, abdomen and pelvis along with panendoscopy was done to evaluate for malignancy. She developed swallowing problems, laryngopharyngeal reflux disease and esophageal dysmotility syndrome within 1 year of diagnosis. Approximately 1.5 years after dermatomyositis diagnosis, she developed a right sided neck mass. Biopsy of the mass found metastatic squamous cell carcinoma. Further work up revealed an ulcerating cavity under tonsillolith containing abnormal tissue and this was thought to be the primary malignancy. RESULTS: Patient underwent right radical neck dissection and tonsillectomy followed by chemotherapy and radiation and her muscle strength, facial rash, burning pains and swallowing difficulties improved. CONCLUSION: To our knowledge, this is the first case of dermatomyositis in the setting of tonsillar squamous cell carcinoma. High suspicion of nasopharyngeal carcinoma should be maintained in dermatomyositis patients with otherwise negative routine malignancy screening who exhibit any pharyngeal or esophageal complaints

Macroglossia in Inclusion Body Myositis

OBJECTIVE: Discussion of a case of Inclusion body myositis (IBM) associated with macroglossia. INTRODUCTION: IBM is one of the idiopathic inflammatory myopathies. Exact pathogenesis is unclear but there is an evidence of dysregulation of antigen driven immune response involving T cells. Typical onset is slowly progressive impacting quadriceps often more than hip flexors, ankle dorsiflexors and distal forearm flexor muscles. Swallowing difficulties often are present and mild facial weakness can be seen. Macroglossia has never been reported in association with IBM. In fact inflammatory myopathies of tongue are a rarity. DESIGN: A case report of a 68 year old woman with 12 year progressive difficulty getting out of chair and inability to twist jar lids. Examination showed forearm flexor and quadriceps atrophy and bilateral face, hip flexion and finger flexion weakness. Clinical diagnosis of IBM was further supported by muscle biopsy findings. One year after the diagnosis, she reported painless progressive enlargement of her tongue resulting in difficulty with chewing. On exam the tongue looked enlarged. MRI of the oropharynx was unremarkable. Tongue muscle biopsy showed non-granulomatous inflammatory infiltrates, myophagocytosis and degenerating regenerating fibers without evidence of amyloidosis. Work up for Sarcoidosis with Chest CT and ACE levels was negative. RESULTS: Decision to start patient on steroids for idiopathic myositis of the tongue was deferred as our patient is currently enrolled in an IBM clinical trial. CONCLUSION: Macroglossia in IBM patients has never been reported in literature. Two reported cases of macroglossia were associated with dermatomyositis and granulomatous myositis. It remains unknown whether this is the first reported case of IBM associated with macroglossia or macroglossia due to a second inflammatory myositis

A case of human parvo virus B 19 infection with erythroid hypoplasia and Idiopathic thrombocytopenic purpura in an immunocompetent child: a case report

Human parvo virus B19 (B19V) is a small (5.5kb) single stranded DNA (deoxy ribo nucleic acid) virus with known tropism and cytotoxicity for erythroid progenitors. Human parvovirus B19 infection is associated with various hematological disorders like aplastic crisis, erythroid hypoplasia and idiopathic thrombocytopenic purpura. Here we are presenting a rare case of parvo virus B19 infection with erythroid hypoplasia and idiopathic thrombocytopenic purpura occurring simultaneously in a 13year old girl who presented with fever and bleeding manifestations. A 13 year old girl presented with fever of 5 days duration, epistaxis and bleeding gums spontaneously of one day duration. On admission she had pancytopenia. Her B12 and folate levels were within normal range. Bone marrow aspiration suggestive of normal cellularity with paucity of erythroid precursors, myeloid: erythroid ratio 9:1 and gaint basophilic pronormoblasts with intra-nuclear inclusions, with no further maturation, as well as increased megakaryocytes with few hypolobate forms suggestive of erythroid hypoplasia and idiopathic thrombocytopenic purpura. Parvo virus B19 DNA PCR by nested polymerase chain reaction was detected in serum. She was treated with blood component support and with steroids for idiopathic thrombocytopenic purpura. She recovered and her cell counts are improved. This case highlights the morphology of Human parvo virus B19 inclusions and its association with simultaneous presentation of erythroid hypoplasia and idiopathic thrombocytopenic purpura in immunocompetent child, which is very rare

Status of Simulation-Based Training in Departments of Surgery in the United States

Background: Surgical simulation is particularly attractive because it allows training in a safe, controlled, and standardized environment. However, the status of surgical simulation among Departments of Surgery (DoS) in the United States is unknown. The objective of this study was to characterize the status of simulation-based training in DoS in the United States. Materials and methods: A Qualtrics online survey was sent to 177 chairs of DoS in the United States in March 2018 regarding the utilization of surgical simulation in their department. Questions in the survey were focused on simulation capacities and activities as well as chairs' perception of the value and purpose of simulation. Results: A total of 87 of 177 chairs responded to the survey (49% response rate). Most programs had either 20-50 trainees (42 of 87; 48%) or more than 50 trainees (37 of 87; 43%). Most chairs reported having a simulation center in their institution (85 of 87; 98%) or department (60 of 86; 70%) with a formal simulation curriculum for their trainees (83 of 87; 95%). Ninety percent (78 of 87) of DoS had protected time for simulation education for their residents, with most residents engaging in activities weekly or monthly (65 of 85; 76%). Although most chairs felt simulation improves patient safety (72 of 84; 86%) and is useful for practicing surgeons (68 of 84; 81%), only 40% reported that faculty use simulation to maintain technical skills and only 17% reported that faculty use simulation to address high complication rates. Conclusions: The vast majority of the DoS in the United States have established simulation activities for their trainees. However, engagement of faculty in simulation to maintain or improve their skills remains low