Search

Acute generalized exanthematous pustulosis is an infrequent but severe pattern of cutaneous adverse reaction. It is characterized by the sudden appearance of sterile pustules on edematous-erythematous skin, which is mostly caused by the consumption of medications. However, it may also be associated with viral infections, toxins, or food allergens, although this is rare. We reported a case of AGEP in a 33-year-old male shortly after a spider bite, a rare cause of AGEP. It was improved by oral corticosteroid treatment after seven days.

Key Clinical Message: Clinicians should be aware of the occurrence of deep vein thrombosis following brown recluse spider bite. [ABSTRACT FROM AUTHOR]

Systemic or cutaneous-visceral loxoscelism is the most severe clinical presentation of loxoscelism. Currently there is no validated laboratory diagnostic method that allows us to confirm the presence of this disease in the face of arachneism. However, there is a clinical prediction rule (CPR), which allows us to predict the evolution of a bite towards a systemic condition and which would be useful in emergency rooms. We present the case of a woman who developed the systemic picture of loxoscelism to whom a new CPR was applied for the early detection of systemic loxoscelism, presenting adequate performance for early evaluation in emergency services.

We report an interesting clinical case of Acquired Haemophilia A (AHA) after a probable Loxosceles rufescens spider bite in a 73- year-old woman, admitted to an Emergency Department (ED) of Central Italy during April 2019. AHA is a rare disease, whose acute clinical manifestations are not widely known by most ED physicians; its prompt recognition and treatment are crucial to avoid fatal bleeding. In particular, the development of AHA after a violin spider bite (another rare and poorly characterized clinical condition) has never been described. Therefore, our case report could provide useful insight into the understanding and treatment of such unusual and possibly life-threatening conditions.

We report an interesting clinical case of Acquired Haemophilia A (AHA) after a probable Loxosceles rufescens spider bite in a 73-year-old woman, admitted to an Emergency Department (ED) of Central Italy during April 2019. AHA is a rare disease, whose acute clinical manifestations are not widely known by most ED physicians; its prompt recognition and treatment are crucial to avoid fatal bleeding. In particular, the development of AHA after a violin spider bite (another rare and poorly characterized clinical condition) has never been described. Therefore, our case report could provide useful insight into the understanding and treatment of such unusual and possibly life-threatening conditions. [ABSTRACT FROM AUTHOR]

Acute generalized exanthematous pustulosis (AGEP) is a toxic cutaneous reaction pattern that is mostly caused by drug intake and rarely associated with spider bites. We report a case of a female patient, 47 years old, with febrile pustular lesions on an erythematous base at the abdominal region. She had three violaceous erythematous and edematous plaques on the interscapular region, one of which had a necrotic crust at its center. The lesions were compatible with spider bites. By considering histopathological and clinical findings, the patient was diagnosed with AGEP. Since she had no history of drug intake, viral infection or other triggers, a spider bite was thought to have caused the AGEP

Loxosceles spp. (brown spiders) bites are responsible for the development of a syndrome consisting mainly of dermonecrotic lesions, and also systemic effects. Rabbits are one of the main experimental models used for better understanding the systemic and local effects of Loxosceles venom. The aim of this study is to evaluate the toxic and protective effects of rabbits immunized with Loxosceles spp. venom. Male New Zealand rabbits were allocated as a control group (CG; n = 5) that received adjuvant (Montanide) and phosphate-buffer saline (PBS), or as venom group (VG; n = 5) that received 21 μg of Loxosceles venom using Montanide as adjuvant. After five immunization cycles, a trial with 7 μg of Loxosceles intermedia (L. intermedia) venom was performed, and dermonecrotic lesions were measured. The rabbits were then euthanized, and their organs were collected for histopathology analysis. Rabbits that had undergone Loxosceles venom immunization protocol showed minor clinical disturbances during the experimental period. The used immunization protocol protected the rabbits against the toxic effect of the Loxosceles venom because they showed minor clinical disturbances during the experimental period.

Vasculitis, or the inflammation of vessels due to primary or secondary causes, may arise from numerous etiologies, often leading to diagnostic uncertainty. Delayed treatment due to diagnostic or etiologic uncertainty presents a significant clinical risk, with consequences including organ failure and mortality. We describe a case of a 58-year-old male with a history including ankylosing spondylitis who presented with painful ulcers involving the bilateral lower extremities following a trip to the southern Texas border. Histopathology revealed medium-vessel vasculitis; however, the search for a likely etiology in the setting of a unique combination of potential vasculitis precipitants, including glochid inoculation, a spider bite, prior IL-17 inhibitor use, and inflammatory bowel disease, contributed to treatment delay and disease progression. Although the patient was ultimately successfully treated with systemic corticosteroids, this case highlights the importance of initiating prompt therapy once vasculitis is recognized to prevent disease progression, even if lacking an identified etiology., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ilsin et al.)

Background/Aim: Brown recluse spider bite releases hemolytic and cytotoxic phospholipase D to the wound that may cause necrosis or even death. We examined diethyl azelate (DEA), a plasma membrane fluidizer with a broad range of immunomodulatory activities, as a potential treatment for the brown recluse spider bite. Materials and Methods: Topical DEA was used in emergency to treat brown recluse spider bites in a human subject. We subsequently evaluated the effects of DEA on hemolysis induced by the brown recluse spider venom, recluse recombinant phospholipase D (rPLD), and venoms from honey bee and moccasin snake, and on phospholipase A2 activity in the bee and snake venoms and in human urine. Results: Topical DEA resolved the consequences of human brown recluse spider envenomation in two weeks. In vitro, DEA inhibited hemolysis caused by the brown recluse spider venom and rPLD and suppressed phospholipase A2 activity in a dosedependent manner. Conclusion: DEA is a promising novel therapy for the brown recluse spider bite and perhaps even unrelated envenomations involving PLDs. [ABSTRACT FROM AUTHOR]

Copyright of People & Nature is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Turkderm - Turkish Archives of Dermatology & Venereology is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Some of the world’s most dangerous spiders have been certified in some areas of Iran. Spider bites are common in some geographical areas, and are sporadic in some regions. Spider bites can be classified as latrodectism or loxoscelism. If the patient had not seen the spider, the clinical manifestations of latrodectism could be easily mistaken for other types of bite or sting; or an infectious disease, and withdrawal symptoms, and also loxoscelism could be mistaken for cellulitis, various types of skin infection, or even a sting from a Gadim scorpion (Hemiscorpius lepturus). Given the nonspecific presentation of spider bites, one must keep the diagnosis in mind, and question patients, regarding possible exposure to spiders. Physicians recommend becoming familiar with the geographical distribution of Iranian dangerous spiders, clinical manifestations, and management of their bites. The most useful treatment for spider bite is anti-venom administration. Producing spider bite anti-venom in the Razi Vaccine and Serum Research Institute is under investigation.

Abstract is missing (Short communication)

Introduction: Accidents involving spiders bites usually cause mild medical reactions that lead to local symptoms and, less commonly, systemic effects. The most medically significant spiders belong to the genera Latrodectus and Loxosceles. This paper presents a posible case of steatodism in a young woman and her pet. Case description: 26-year-old female patient, who reports a clinical history characterized by paresthesia, malaise, fever, diarrea and a painful papule in the left cheek after being bitten by a spider. Immediately after being bit, the patient hit the spider with the back of her hand and it fell to the ground, where her dog swallowed it. The dog presented with vomiting and general discomfort after ingestion. Symptomatic therapy was given for comfort, and neither the patient nor the dog required antivenin therapy. Both evolved favorably. Discussion: The relevance of this case is the involvement of two mammals (a human and her dog) due to the accidental contact with a spider, possibly of the genus Latrodectus or Steatoda. Conclusion: Two possible cases of steatodism are described. Since spider bites are a relatively frequent reason for medical consultation in Colombia, it is important to diagnose and manage them properly.

Black widow spider bites are uncommon in South Africa, but it is important for clinicians to be aware of the clinical presentation in order to initiate appropriate treatment. This case highlights the presentation and management of a middle-aged gentleman who presented to the Chris Hani Baragwanath hospital following a spider bite. The bite was later confirmed to be that of a black widow spider. The patient presented with the typical symptoms of latrodectism – autonomic dysfunction, muscle rigidity and cramps – and was managed symptomatically with a favourable outcome.

In this case report, we discuss a 32-year-old diabetic male patient who presented with right foot pain three days following a spider bite. The foot progressively became swollen, preventing the patient from bearing weight on it. After admission to the emergency department, the examination showed discoloration of the dorsum of the proximal phalanx of the first toe with an open wound and pus. The patient received fluid resuscitation along with a course of metronidazole and levofloxacin. Subsequently, the patient was referred to an orthopedic and podiatric team where he underwent a complete foot fasciotomy. The procedure was successful, and the patient recovered well. This case showcases a rare manifestation of necrotizing fasciitis (NF) and highlights the importance of future research regarding NF and its association with diabetes mellitus., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Nadora et al.)

We performed a retrospective study of 176 patients in the University Hospital Center of Tirana (Albania), during the period 2001–2011, admitted with the diagnosis of a suspected spider bite. Three fatalities were registered during this decade covered from our study, with a clinical picture of marked hypertension, tachycardia and acute cardiac failure leading to death within a minimum of 25 h and a maximum of 42 h from the occurrence. Out of the total of 176 patients, we had 59% (104 cases) females, and 41% males. The overwhelming majority of the patients lived in rural areas (155 of the cases); extremities were mostly affected from the bites. A summary of clinical signs and a brief review of the available literature are made in the results and discussion section of this paper. Authors advocate that special precautions should be taken especially in severe forms of interesting autonomous nerve system, with aggressive fluid resuscitation, supportive therapy and close monitoring of vital signs.

Systemic loxoscelism is a rare complication from the bite of spiders in the genus Loxosceles.These bites usually cause painful indurated skin reactions, including necrosis,and occasionally cause systemic complications, such as rhabdomyolysis, acute renalfailure, and disseminated intravascular coagulation. Our case had multiple systemiccomplications, including bilateral globus pallidus infarcts with right arm weakness.

The patient was an 18-year-old man who developed nephrotic syndrome after a 'wheat spider' bite (Latrodectus mactans). Due to this atypical manifestation of latrodectism, a renal biopsy was performed showing minimal change disease. The nephrotic syndrome subsided after 1 week without specific treatment. This self-limited evolution suggests that the mechanism of podocyte damage was temporary and potentially mediated by a secondary mechanism of hypersensitivity or direct effect of the α-latrotoxin. The patient did not show signs of relapse in subsequent checkup. This is the first reported case of nephrotic syndrome due to a minimal change lesion secondary to latrodectism. [ABSTRACT FROM AUTHOR]

Key Clinical Message The true danger of the spider bite stems from misdiagnosis and resultant delay in proper treatment of entities that, unlike spider bites, are not self-limited. Obtaining a complete exposure and travel history is central to the development of an accurate and appropriate differential diagnosis. [ABSTRACT FROM AUTHOR]

Loxoscelism is caused by envenomation by spiders that belong to the Loxosceles genus. In loxoscelism, a local necrotic lesion appears and, in many cases, loxoscelism or necrotic araneism is considered a serious public health problem. There is no diagnostic test available to help the physician make a diagnostic or therapeutic decision. Here, we report the case of a severe dermonecrotic araneism (loxoscelism) in Turkey probably due to the bite of Loxosceles rufescens. There was little erythema at the beginning, followed by severe necrosis after 20 days, and skin grafting was needed although the case was treated.

Here, we present a case of a 55-year-old male, who was admitted with a spider bite, which caused swelling of the hand and painful muscle spasms along with palpitations. The patient made a complete recovery after the administration of intravenous calcium gluconate, followed by oral calcium supplements. Although no specific treatment exists in Sri Lanka for spider bites, calcium supplements can be beneficial for Sri Lankan ornamental tarantula (Poecilotheria fasciata) bites., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Ramesh et al.)

Black widow spider bites are uncommon in South Africa, but it is important for clinicians to be aware of the clinical presentation in order to initiate appropriate treatment. This case highlights the presentation and management of a middle-aged gentleman who presented to the Chris Hani Baragwanath hospital following a spider bite. The bite was later confirmed to be that of a black widow spider. The patient presented with the typical symptoms of latrodectism - autonomic dysfunction, muscle rigidity and cramps - and was managed symptomatically with a favourable outcome. [ABSTRACT FROM AUTHOR]

Abdominal pain is a common complaint among children with a vast differential diagnosis. Hip pain is also a nonspecific sign. Here, we present a case of a 3-year-old boy with a complaint of abdominal pain and pain in both hips, much on the right one. After evaluations, the diagnosis was a spider bite.

A retrospective study analysed 359 proven or presume cases of loxoscelism seen at the Hospital Vital Brazil, Instituto Butantan, São Paulo, Brazil, between 1985 and 1996. The spider was identified in 14%. The bites occurred predominantly in the urban areas (73%) between September and February. Patients > 14 years were commonest inflicted (92%) and 41% were bitten while getting dressed. Only 11% sought medical care within the first 12 hours post bite. Cutaneous loxoscelism was the commonest form presenting (96%); commonest manifestations were: pain (76%), erythema (72%), edema with enduration (66%), ecchymosis (39%). Skin necrosis occurred in 53% of patients, most frequently seen on trunk, tigh and upper arm, and when patients seek medical care more than 72 hours after bite. Local infection was detected in 12 patients (3%). Hemolysis was confirmed in 4 cases (1.1%). Generalised cutaneous rash, fever and headache were also observed in 48% of the total of patients. None of them had acute renal failure or died. Treatment usually involved antivenom administration (66%), being associated with corticosteroids (47%) or dapsone (30%). Presumptive diagnosis of loxoscelism may be established based on clinical and epidemiological findings. Further investigations are required to prove the value of antivenom and other treatment schedules.

Introduction: The brown recluse spider (BRS) ( Loxosceles reclusa) envenomation can lead to multiple complications, including hemolysis. We present a case of refractory hemolysis after a BRS bite treated with therapeutic plasma exchange (TPE). Case Report: A 17-year-old female presented with fever, fatigue, and dyspnea. She was diagnosed with sepsis and received intravenous (IV) fluids, inotropic support, and antibiotics. On hospital day 1 she was noted to have skin lesion consistent with a BRS bite and developed hemolysis. Systemic loxoscelism with hemolysis was then suspected and methylprednisolone IV was initiated. She was discharged with a stable HGB on hospital day 3 on oral prednisolone. She was re-admitted 24 h later, with signs of worsening hemolysis. Methylprednisolone was restarted and she was transfused 4 units of packed red blood cells. TPE was initiated due to the refractory hemolysis. Shortly after the TPE session, her clinical and laboratory status improved. She required no further transfusions and was discharged on a steroid taper. Discussion: TPE is an extra-corporeal method to remove substances from the blood by separating plasma from cellular blood components and replacing it with physiologic fluids. TPE has been used for snake envenomation but there are no reports detailing its use for BRS envenomations. Improvement was associated with TPE initiation and may have been due to removal of complement components activated by the spider venom. This report suggests that TPE could be a possible treatment modality for systemic loxoscelism with refractory hemolysis due to BRS envenomation. Further investigation is warranted. [ABSTRACT FROM AUTHOR]

We performed a retrospective study of 176 patients in the University Hospital Center of Tirana (Albania), during the period 2001–2011, admitted with the diagnosis of a suspected spider bite. Three fatalities were registered during this decade covered from our study, with a clinical picture of marked hypertension, tachycardia and acute cardiac failure leading to death within a minimum of 25 h and a maximum of 42 h from the occurrence. Out of the total of 176 patients, we had 59% (104 cases) females, and 41% males. The overwhelming majority of the patients lived in rural areas (155 of the cases); extremities were mostly affected from the bites. A summary of clinical signs and a brief review of the available literature are made in the results and discussion section of this paper. Authors advocate that special precautions should be taken especially in severe forms of interesting autonomous nerve system, with aggressive fluid resuscitation, supportive therapy and close monitoring of vital signs. [ABSTRACT FROM AUTHOR]

Background: Acute generalized exanthematous pustulosis (AGEP) is a rare and severe cutaneous reaction usually triggered by drugs. Other causative factors such as viral infections are rarely involved. In this study, we report a case of AGEP caused by a spider bite. Case Summary: A 56-year-old woman was referred to the allergy unit after a spider bite at the left popliteal fossa, while gardening, 5 days earlier. The offending spider was captured and identified by an entomologist as belonging to the Loxosceles rufescens species. No acute reaction was observed; however, after 24 hours, due to the occurrence of typical dermonecrotic skin lesions associated with erythema and edema, Cefuroxime and Clindamycin were administered intramuscularly after medical advice was given. Almost 72 hours after the spider bite, an erythematous and partly edematous eruption appeared locally in the gluteus area bilaterally, which progressively expanded to the trunk, arms and femors. Within 24 hours dozens of small, pinhead sized, non- follicular pustules were present, mainly in the folds. The patient complained of a burning sensation of the skin in addition to pruritus; and simultaneously had a fever of 38-39 °C as the eruption expanded. Discussion: A spider bite may represent a possible causative factor of AGEP. A spider's venom contains sphingomyelinase that stimulates the release of IL8 and GM-CSF, which are involved in AGEP pathogenesis. Whether or not the con-current use of antibiotics has an effect in AGEP appearance when combined with a spider's venom, cannot be excluded.

Recent research has found that one vial of antivenom is sufficient for the treatment of envenomation by all five major groups of Australian snakes. In snake bite coagulopathy, serial coagulation testing helps determine when patients can be safely discharged, but abnormal results are not an indication for further antivenom. Clinically significant rhabdomyolysis is more common than previously realised in red-bellied black snake envenomation. Early antivenom administration may prevent rhabdomyolysis, but it is unclear if this benefit outweighs the risk of adverse reactions to antivenom. Analgesia is the mainstay of treatment for redback spider bite. Early and effective cardiopulmonary resuscitation is more important than antivenom in box jellyfish envenomation. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To classify and characterize spider bites among inquiries to the National Poison Information Center (NPIC) between 1995 and 2004, in terms of the epidemiology and clinical symptomatology. Methods: Clinical and epidemiological data were obtained from the NPIC''s patient records. The following information was recorded for each spider bite: demographics, circumstances of the bite, and local and systemic effects. Results: A total of 82 cases were reported. The accidents were mostly seen during August. The gender distribution was 59.76% male, 37.20% female, and 2.44% unknown and the 20–29 age group presented more spider bites. Most of the cases were in the Central Anatolia, Marmara, Mediterranean, and Black Sea regions. Local symptoms were observed in 60.87% of the cases, including local pain, edema, redness, itching, debris, burning, and numbness. Systemic symptoms were observed such as nausea, vomiting, abdominal pain, lethargy, anxiety, weakness, somnolence, dyspnea, hypertension, hypotension, and hyperthermia. Conclusions: In conclusion, these findings emphasize the presence of medically important spider species in Turkey. All patients and especially pediatric patients should be admitted to the hospital. Identification of spider species may be considered a useful clinical and epidemiological tool in determining the incidence and risk of spider bites. [Copyright &y& Elsevier]

Reports of spider bites appear throughout North America. Bites associated with the brown recluse spider (Loxosceles recluse) cause serious medical complications because the venom of this spider contains a powerful necrotising agent with the potential to cause severe cutaneous necrosis. Although not much is known regarding the application of negative pressure wound therapy (NPWT) to spider bites, this therapy has considerable literature support for its efficacy, cost-effectiveness and ease of use in chronic, difficult-to-heal wounds. A case study using NPWT to successfully treat a non healing upper arm wound presumed due to a venomous spider bite is presented here. The patient was successfully treated with a new, less costly NPWT product called the Versatile 1® and a new combination drain plus dressing called the Miller DermiVex® drain, both manufactured by Blue Sky Medical (Carlsbad, CA). [ABSTRACT FROM AUTHOR]

Spider bites, including the bites of recluse spiders ( Loxosceles , also known as brown spiders), usually lead to local symptoms; however, severe systemic symptoms have also been reported in the literature. Management of spider bites is based on symptoms. In severe cases involving the development of angioedema, hemolytic anemia, skin necrosis with superimposed bacterial infection or disseminated intravascular coagulation, antibiotics, steroids, blood transfusions, and plasma exchange may also play a role. We present a case of a brown recluse spider bite resulting in symptomatic hemolytic anemia and jaundice requiring blood transfusion., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Talib et al.)

Spiders of the Loxosceles species can cause dermonecrosis and acute kidney injury (AKI). Hemolysis, rhabdomyolysis and direct toxin‑mediated renal damage have been postulated. There are very few reports of Loxoscelism from India. We report a case of AKI, hemolysis and a “gravitational” pattern of ulceration following the bite of the brown recluse spider (Loxosceles spp). [ABSTRACT FROM AUTHOR]

There are a thousand of species of spiders, but a few are of medical importance. Phoneutria genus is one of the most aggressive spiders, popularly known as the “Brazilian wandering spider". Phoneutrism cases can be divided into mild, moderate and severe based on clinical symptomatology. The clinical signs are intense pain, edema, mild erythema, emesis, tachycardia, agitation, hypotension, cardiac arrhythmia, pulmonary edema, seizure, priapism and shock. Cardiac troponin I (cTnI) and creatine phosphokinase MB (CKMB) can be used to measure myocardial damage caused by phoneutrism. The aim of this study is report the use of cardiac biomarkers as tool to identify cardiac damage of phoneutrisms in a dog. A one-year-old, mixed breed, male, eight kilograms dog was brought to the Veterinary Hospital presenting yellowish liquid emesis, muscle tremors and disorientation after being bitten by Phoneutria nigriventer identified by Laboratory of Veterinary Toxicology. There were restless behavior, paresis of pelvic limbs and intense muscular fasciculations, tachycardia (140 bpm), tachypnea, dyspnea, weak arterial pulse, cyanotic mucosa, mild dehydration (< 5%), cardiac arrhythmia, pulmonary crepitation, decubitus with tetraparalysis and hyperventilation. A total absence of response to the postural tests was observed on neurological examination. There were absence of pupillary and palpebral reflexes, bilateral miosis, with the right side being lightly responsive, an increase in muscle tone in both pelvic and thoracic limbs with spastic characteristics, anterior patellar reflex was absent, the panicle reflex was diminished, and the animal was incontinent. Hemogram, biochemical tests, gasometry and urinalysis was performed. In venous blood gas analysis, hypokalemia (K + 2.91 mmol/L) and decrease of ionized calcium (iCa 1.84 mg/dL) were observed. Blood pressure was 160 mmHg. The total CK dosage was 2585U/L (reference value = 84 U/L). The treatment was oxygen therapy, furosemide (4 mg/ kg, SC), tramadol (3 mg/kg, IV), intravenous fluid therapy with ringer-lactate (78 mL/hour) supplemented with calcium gluconate and potassium chloride. Omeprazole (1 mg/kg, IV, SID) was added to cephalothin (30 mg/kg, IV, TID). At electrocardiogram, bradyarrhythmia was detected with atrial extrasystoles. The analysis of the two cardiac markers, cTnI and CK-MB were requested. Both were increased (CK-MB [194 U/L] and cTnI [10.78 ng/mL]. On the second day, the dog was agitated, walked normally and fed on appetite. A new dosage of electrolytes performed was within the reference values. The animal was discharged as soon as the fluid therapy was completed. A week later, the animal returned with all parameters within normality; no change was observed on the second electrocardiogram. Even though the condition was considered severe, the dog had good clinical improvement, possible due to the rapid evaluation, including cardiac alterations of the animal and immediate institution of the therapy support. [ABSTRACT FROM AUTHOR]