A Case Report of Hemiplegic Migraine with Mutation in the ATP1A2 Gene.

Background: Hemiplegic migraine, a less common variant of migraine, is the focus of this paper. Within the scope of this study, we present a case of hemiplegic migraine that bears the potential for misdiagnosis, particularly as encephalitis. Brief introduction to the Disease: The patient developed a right-sided headache a day prior to admission, accompanied by fever, nausea, vomiting, and left-sided limb weakness. On the fourth day, the patient experienced a grand mal epilepsy, marked by unconsciousness, leftward deviation of both eyes, limb convulsions, and foaming at the mouth. Cerebrospinal fluid analysis revealed no apparent abnormalities, Electroencephalography showed abnormal slow waves, imaging studies indicated swelling and meningeal thickening in the right cortex, and genetic testing identified a heterozygous mutation in the ATPIA2 gene. The diagnosis was hemiplegic migraine, and the patient received symptomatic supportive treatment, leading to improvement and subsequent discharge. Flunarizine and sodium valproate were prescribed post-discharge, and the patient achieved complete recovery after a one-month follow-up. Conclusion: Apart from experiencing headaches, patients with hemiplegic migraine may exhibit additional symptoms like fever, epilepsy, and hemiplegia. These manifestations warrant clinical attention, and if deemed necessary, genetic testing should be conducted, and this is an autosomal dominant pattern.

Unusual Location of a Rare Tumor: Cutaneous Myxoma of the Scrotum.

Myxoma is a rare benign mesenchymal neoplasm. Scrotal myxomas can be either cutaneous or intramuscular. Muscular myxomas are usually found in cardiac muscles and skeletal muscles of the extremities. The most common locations of cutaneous myxomas are the trunk, lower extremities, and the head and neck. However, these lesions can rarely arise in the genital area (vulva, mons pubis, and scrotum). The clinical presentation of this lesion is nonspecific, and it is difficult to make a diagnosis before a biopsy and microscopic examination. Scrotal myxomas are infrequent and can cause definite diagnostic problems.  We report a case of a 64-year-old male who presented to the surgery outpatient department with a history of scrotal swelling for 20 years. The swelling was excised and sent for histopathological examination. Histopathological examination revealed features of scrotal cutaneous myxoma.

A 50-year-old patient with pancreatitis revealing pancreatitis, panniculitis, and polyarthritis syndrome-a case report and review of the literature.

The combination of pancreatitis, panniculitis, and polyarthritis (PPP) is a rare systemic syndrome that occurs in patients with acute or chronic pancreatitis or pancreatic malignancies. A 50-year-old male patient presented with polyarthritis increasing for 1 week and consequent inability to walk unaided. In addition, the patient had several isolated nodules on the lower extremities without any tenderness to pressure. Laboratory tests showed elevated pancreatic enzymes indicative of pancreatitis, which was thereafter confirmed by abdominal CT scan, with signs of chronic pancreatitis and concrements in the pancreatic duct. The diagnosis of panniculitis was established by dermatological consultation. Considering all these clinical features, PPP syndrome was diagnosed. In accordance with the pre-existing literature, oral glucocorticoid therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) were given but failed to improve pain and polyarthritis. In the further clinical course, due to the persistent increase in lipase and amylase, endoscopic retrograde cholangiopancreatography (ERCP) was performed, showing small concrements in the pancreatic duct. During the intervention, the pancreatic duct was widened, the small concrements were removed, and a pancreatic duct stent was then implanted. Following ERCP, an instant decrease in pancreatic enzymes was observed, accompanied by a clear and sustained improvement of joint swellings and pain. With the typical triad of clinical findings in mind, one should consider PPP syndrome in the context of acute or chronic pancreatitis as well as in pancreatic malignancies. All involved disciplines (gastroenterology, dermatology, and rheumatology) should be familiar with this rare but severe condition. The prognosis depends on the extent of the functional deficit of the extremities and the progression of the underlying disease.

Important Role of Ultrasonography Immediately After Fine-Needle Aspiration Biopsy of Thyroid Nodules to Detect Acute Transient Thyroid Swelling.

OBJECTIVE: We aimed to determine whether early detection of acute transient thyroid swelling (ATTS) is possible using ultrasonography (US) surveillance immediately after fine-needle aspiration biopsy (FNAB) and discuss the usefulness of routine US after FNAB. METHODS: We retrospectively evaluated the incidence, clinical features, and US and computed tomography findings of ATTS in patients with thyroid nodules who underwent FNABs at our hospital. The study period was divided into two time periods: only symptomatic patients after FNAB were examined using US in the first period (period A: January 2016 to November 2020), whereas all patients were routinely examined using US shortly after FNAB in the second period (period B: December 2020 to December 2022). RESULTS: We found that the frequency of ATTS increased from 0.18% (10/5,685) in period A to 1.58% (31/1,958) in period B because the majority of ATTS cases in period B were asymptomatic. Follow-up US performed 15 minutes to 3 hours later confirmed no exacerbation of thyroid swelling in patients diagnosed with ATTS during period B. Routine US examinations, shortly after FNAB, significantly reduced the number of return visits after discharge (from 5/10 to 2/31, p=0.006). Furthermore, the incidence of unilateral swelling was higher than previously reported. CONCLUSION: Routine US examinations shortly after FNAB may be useful in identifying ATTS regardless of the presence of symptoms; moreover, they may reduce patients' return visits after leaving the hospital. It is also important to inform patients that delayed complications are possible and that severe cases, although rare, do exist.

Hemangioma of the Tongue: A Case Report.

Vascular anomalies include a wide range of tumors and malformations. Hemangioma is the most frequent vascular defect. Hemangiomas are benign endothelial cell tumors most frequently detected in children but uncommon in adults. Most of them affect the neck and head regions but rarely involve the palate, lips, tongue, and buccal mucosa. Treatment for oral hemangiomas should begin as soon as possible because they are clinically significant. Patients are at an increased risk of developing tongue hemangiomas due to the tongue's high flexibility and muscular structure, which makes it more vulnerable to trauma and its effects. They grow and proliferate within a few weeks of birth, with the majority of their components undergoing involution. Females are more likely than males to develop hemangiomas. Hemangiomas are treated with surgery, laser therapy, radiofrequency, sclerosing agents, radiation treatment, cryosurgery, corticosteroids, embolization, electrocauterization, and interferon. When assessing treatment options for hemangiomas, it is crucial to consider various criteria, such as the lesion's hemodynamics, the patient's age, and the location, size, and feasibility of the planned procedure. This report describes a case of a 19-year-old female diagnosed with a hemangioma located on the middle third of the dorsal aspect of the right lateral border of the tongue.

Metallic and metallic oxide nanoparticles toxicity primarily targets the mitochondria of hepatocytes and renal cells.

Nanoparticles (NPs) are utilized in various applications, posing potential risks to human health, tissues, cells, and macromolecules. This study aimed to investigate the ultrastructural alterations in hepatocytes and renal tubular cells induced by metallic and metal oxide NPs. Adult healthy male Wistar albino rats (Rattus norvegicus) were divided into 6 (n = 7) control and 6 treated groups (n = 7). The rats in the treated groups exposed daily to silver NPs, gold NPs, zinc oxide NPs, silicon dioxide NPs, copper oxide NPs, and ferric oxide NPs for 35 days. The members of the control group for each corresponding NPs received the respective vehicle. Liver and kidney tissue blocks from all rats were processed for Transmission Electron Microscopy (TEM) examinations. The hepatocytes and renal tubular cells of all NPs-treated rats demonstrated mitochondrial ultrastructural alterations mainly cristolysis, swelling, membrane disruption, lucent matrices, matrices lysis, and electron-dense deposits. However, other organelles demonstrated injury but to a lesser extent in the form of shrunken nuclei, nuclear membrane indentation, endoplasmic reticulum fragmentation, cellular membranes enfolding, brush border microvilli disruption, lysosomal hyperplasia, ribosomes dropping, and peroxisome formation. One may conclude from the findings that the hepatocytes and the renal tubular cells mitochondria are the main targets for nanoparticles toxicity ending in mitochondrial disruption and cell injury. Further studies taking into account the relation of mitochondrial ultrastructural damage with a weakened antioxidant defense system induced by chronic exposure to nanomaterials are needed.

Rice Body Formation in an Enterococcus faecalis-Infected Total Hip Arthroplasty Causing Sciatic Nerve Compression.

We present a case of a 73-year-old lady with a previous uncemented left total hip arthroplasty (THA) three years prior to her current presentation. She presented with an enlarging 'granulomatous'-looking swelling at the distal aspect of her THA scar for three months that was associated with shooting pain from the posterior aspect of her hip radiating down to her foot. The culture and sensitivity of her hip aspirate revealed the growth of Enterococcus faecalis. She underwent revision surgery utilising a 'well-fixed' Exeter custom-made articulating spacer (CUMARS). Intra-operatively, a large encapsulated cyst containing rice bodies was discovered deep within the fascia lata. A complete excision of this cyst was performed. Post-operatively, the patient was treated with two weeks of IV antibiotics and ten weeks of oral antibiotics. Histopathological examination confirmed the presence of rice bodies, with no malignancy seen. We aim to highlight the possibility of rice body cyst formation in the setting of a periprosthetic joint infection (PJI) around a THA and the importance of early treatment in such cases. This is the first published report of a rice body cyst formation in an infected THA.

Mullerian Duct-Type Clear Cell Adenocarcinoma of the Urethra in a Woman Presenting As Groin Swelling.

Primary Mullerian duct-type clear cell adenocarcinoma of the urethra is a rare clinical entity with a varied clinical presentation. This can be diagnosed only with a high index of suspicion. Clinical examination, biopsy, and immunohistochemistry are essential for diagnosis. Management will need a multimodal approach with a combination of chemotherapy and surgical excision.

Temperature-Regulated Synthesis of Hyaluronic Acid-Interpenetrated Polyacrylamide/Poly(Acrylic Acid Sodium Salt) Semi-Interpenetrated Polymer Network Gel for the Removal of Methyl Violet.

An alternative synthetic pathway was proposed for the optimization of synthesis to find a better correlation between the swelling and elasticity of hyaluronic acid-interpenetrated gels via temperature regulation. An experimental design methodology was presented for the synthesis of polyacrylamide/poly(acrylic acid sodium salt)/hyaluronic acid, PAAm/PSA/HyA, gels by modifying the one-pot procedure using free radical crosslinking copolymerization of AAm with the addition of anionic linear PSA chains in the presence of various amount of HyA, ranging between 0.05% and 0.20% (w/v). Semi-interpenetrated polymer network (IPN)-structured gels were designed with tunable elasticity, in which the extent of covalent crosslinking interactions is controlled by polymerization temperature ranging between -18 and 45 °C. Depending on the HyA content added in the synthesis and the polymerization temperature, the swelling ratio could be controlled. The addition of 0.05% (w/v) HyA increased the swelling of semi-IPNs, while the elastic modulus increased with increasing HyA content and decreased with the polymerization temperature. PAAm/PSA/HyA semi-IPNs showed the typical pH-sensitive swelling of anionic gels, and the swelling reached a maximum at a pH of 11.2. PAAm/PSA/HyA gels were tested for the removal of methyl violet from wastewater. Adsorption kinetics were shown to be well-fitted with the pseudo-second-order model using linear and nonlinear regression analysis. With the clear relationship between increased modulus and composition, this study enabled the fine-tuning of semi-IPN interactions by varying the polymerization temperature.

Preparation and Characterization of Preformed Polyelectrolyte and Polyampholyte Gel Particles for Plugging of High-Permeability Porous Media.

Excessive reservoir water poses significant challenges in the oil and gas industry by diminishing hydrocarbon recovery efficiency and generating environmental and economic complications. Conventional polymer flooding techniques, although beneficial, often prove inadequate under conditions of elevated temperature and salinity, highlighting the need for more resilient materials. In this research, two types of acrylamide-based preformed particle gels (PPGs) were synthesized, as follows: polyelectrolyte and polyampholyte. These PPGs were engineered to improve plugging efficiency and endure extreme reservoir environments. The polyelectrolyte gels were synthesized using acrylamide (AAm) and sodium acrylate (SA), while the polyampholyte gels incorporated AAm, AMPS, and APTAC, with crosslinking achieved through MBAA. The swelling properties, modulated by temperature, salinity, and pH, were evaluated using the Ritger-Peppas and Yavari-Azizian models. The mechanical characteristics and surface morphology of the gels were analyzed using SEM and BET techniques. In sand pack experiments designed to mimic high-permeability reservoirs, the inclusion of 0.5 wt.% of fine PPGs substantially reduced water permeability, outperforming traditional hydrogels. Notably, the polyampholyte PPGs demonstrated superior resilience and efficacy in plugging. However, the experiments were limited by the low test temperature (25 °C) and brine salinity (26.6 g/L). Future investigations will aim to apply these PPGs in high-temperature, fractured carbonate reservoirs.

Green Synthesis of ZnO Nanoparticles via Ganoderma Lucidum Extract: Structural and Functional Analysis in Polymer Composites.

Metallic nanoparticles are of growing interest due to their broad applications. This study presents the green synthesis of zinc oxide (ZnO) nanoparticles (ZnNPs) using Ganoderma Lucidum mushroom extract, characterized by DLS, SEM, XRD, and FTIR spectroscopy analyses. The synthesis parameters, including extract/salt ratio and mixing time, significantly influenced nanoparticle yield, size, and polydispersity, with longer mixing times leading to larger, more varied particles. Specifically, the sizes of ZnNPs synthesized at a 1:1 extract/ZnCl2 ratio after 3 h and 24 h were 90.0 nm and 243.3 nm, with PDI values of 48.69% and 51.91%, respectively. At a 1:2 ratio, the sizes were 242.3 nm at 3 h (PDI: 43.19%) and a mixture of 1.5 nm, 117.4 nm, and 647.9 nm at 24 h (PDI: 2.72%, 10.97%, and 12.43%). Polymer films incorporating PVA, chitosan, and ZnNPs were analyzed for their morphological, spectroscopic, and mechanical properties. Chitosan reduced tensile strength and elongation due to its brittleness, while ZnNPs further increased film brittleness and structural degradation. A comparison of the tensile strength of films A and C revealed that the addition of chitosan to the PVA film resulted in an approximately 10.71% decrease in tensile strength. Similarly, the analysis of films B1 and B2 showed that the tensile strength of the B2 film decreased by 10.53%. Swelling tests showed that ZnNPs initially enhanced swelling, but excessive amounts led to reduced capacity due to aggregation. This pioneering study demonstrates the potential of Ganoderma Lucidum extract in nanoparticle synthesis and provides foundational insights for future research, especially in wound dressing applications.

The Influence of the Structural Architecture on the Swelling Kinetics and the Network Behavior of Sodium-Alginate-Based Hydrogels Cross-Linked with Ionizing Radiation.

The present work discusses the influence of the structural architecture of sodium alginate-co-acrylic acid-poly(ethylene) oxide hydrogels, crosslinked through electron beam (e-beam) radiation processing. The most important properties of the hydrogels were studied in detail to identify a correlation between the architecture of the hydrogels and their properties. Furthermore, the effect of sodium alginate (NaAlg) concentration, the amounts of the polymer blend, and the size of the samples on hydrogel properties were investigated. The results show that the hydrogels cross-linked (0.5% and 1% NaAlg) with 12.5 kGy exhibit improved physicochemical properties. High gel fraction levels (exceeding 83.5-93.7%) were achieved. Smaller hydrogel diameter (7 mm) contributed to a maximum swelling rate and degree of 20.440%. The hydrogel network was dependent on the hydrogels' diameter and the amount of polymer blend used. The hydrogels best suited the first-order rate constants and exhibited a non-Fickian diffusion character with diffusion exponent values greater than 0.5. This study indicates that the cross-linked hydrogel has good properties, particularly because of its high degree of swelling and extensive stability (more than 180 h) in water. These findings show that hydrogels can be effectively applied to the purification of water contaminated with metals, dyes, or even pharmaceuticals, as well as materials with a gradual release of bioactive chemicals and water retention.

Poly(acrylic acid)-Sodium Alginate Superabsorbent Hydrogels Synthesized by Electron-Beam Irradiation-Part II: Swelling Kinetics and Absorption Behavior in Various Swelling Media.

Hybrid hydrogels with superabsorbent properties based on acrylic acid (20%), sodium alginate (0.5%) and poly(ethylene oxide) (0.1%) were obtained by electron-beam irradiation between 5 and 20 kGy, and are characterized by different physical and chemical methods; the first results reported showed gel fractions over 87%, cross-link densities under 9.9 × 103 mol/cm3 and swelling degrees of 400 g/g. Two types of hydrogels (without and with 0.1% initiator potassium persulfate) have been subjected to swelling and deswelling experiments in different swelling media with different pHs, chosen in accordance with the purpose for which these superabsorbent materials were obtained, i.e., water and nutrients carriers for agricultural purposes: 6.05 (distilled water), 7.66 (tap water), 5.40 (synthetic nutrient solution) and 7.45 (organic nutrient solution). Swelling kinetics and swelling dynamics have been also studied in order to investigate the influence of swelling media type and pH on the absorption phenomenon. The swelling and deswelling behaviors were influenced by the hydrogel characteristics and pH of the swelling media. Both the polymeric chain relaxation (non-Fickian diffusion) and macromolecular relaxation (super case II) phenomenon were highlighted as a function of swelling media type.

Flow Dynamics through a High Swelling Nanofiber Membrane Processed at Different Relative Humidities: A Study on a FexOy/Polyvinyl Alcohol Composite.

Addressing the global problem of polluted water requires sustainable, efficient, and scalable remediation solutions, such as electrospun polyvinyl alcohol (PVA) membranes incorporating specific nanoadsorbents. The retention of contaminants depends on membrane swelling, morphology, and the adsorbent within the nanofiber. This study investigated the effect of relative humidity (RH) within the electrospinning chamber on the morphology of the resulting mats and how this affected the flow dynamics depending on whether or not the permeating liquid induced swelling in the membranes. An insolubilized PVA membrane was used as a hydrophilic filter model and a PVA membrane filled with iron oxide nanoparticles (IONPs) as a composite model (PVA + IONPs). The presence of IONPs increases the nanofiber diameter, which decreases when prepared under intermediate RH (IRH). Consequently, the nanofiber configuration, which is critical for filtration tortuosity, is influenced by RH. The initial swelling results in over 60% greater water flux through PVA + IONPs compared to PVA at an equivalent RH. This characterization helps to optimize membrane applications, highlighting that PVA + IONPs exhibit lower permeability values at IRH, indicating improved contaminant retention capabilities.

Anisotropic swelling due to hydration constrains anisotropic elasticity in biomaterial fibers.

Naturally occurring protein fibers often undergo anisotropic swelling when hydrated. Within a tendon, a hydrated collagen fibril's radius expands by 40% but its length only increases by 5%. The same effect, with a similar relative magnitude, is observed for single hair shafts. Fiber hydration is known to affect elastic properties. Here we show that anisotropic swelling constrains the anisotropic linear elastic properties of fibers. First we show, using data from disparate previously reported studies, that anisotropic swelling can be described as an approximately linear function of water content. Then, under the observation that the elastic energy of swelling can be minimized by the anisotropic shape, we relate swelling anisotropy to elastic anisotropy - assuming radial (transverse) symmetry within a cylindrical geometry. We find an upper bound for the commonly measured axial Poisson ratio νzx<1/2. This is significantly below recently estimated values for collagen fibrils extracted from tissue-level measurements, but is consistent with both single hair shaft and single collagen fibril mechanical and hydration studies. Using νzx, we can then constrain the product γ≡(1-νxy)Ez/Ex - where νxy is the seldom measured transverse Poisson ratio and Ez/Ex is the ratio of axial to radial Young's moduli.

Molecular Chain Rearrangement-Induced In Situ Formation of Nanofibers for Improving the Strength and Toughness of Hydrogels.

Although poly(vinyl alcohol) (PVA) hydrogel has high elasticity and is suitable for cartilage tissue engineering, it is difficult to have both high strength and toughness. In this study, a simple and universal strategy is proposed to prepare strong and tough PVA hydrogels by in situ forming nanofibers on the original network structure induced by a molecular chain rearrangement. Quenching-tempering alteratively in ethanol and water several times is carried out to strengthen PVA hydrogels (PVA-Etn hydrogels) due to the advantages of noncovalent bonds in adjustability and reversibility. The results show that, after three quenching-tempering cycles, PVA-Et3 hydrogel with water content up to 79 wt % shows comprehensive improved mechanical properties. The compression modulus, tensile modulus, fracture strength, tensile strain, and tear energy of the PVA-Et3 hydrogel are 270, 250, 260, 130, and 180% of the initial PVA hydrogel, respectively. The improved mechanical properties of the PVA-Et3 hydrogel are attributed to the strong cross-linked PVA chains and hydrogen bond-reinforced nanofibers. This study not only provides a simple and efficient solution for the preparation of strong and tough polymer scaffolds in tissue engineering but also provides new insights for understanding the mechanism of improving the mechanical properties of polymer hydrogels by adjusting the molecular structure.

A low-swelling alginate hydrogel with antibacterial hemostatic and radical scavenging properties for open wound healing.

Development of a low-cost and biocompatible hydrogel dressing with antimicrobial, antioxidant, and low swelling properties is important for accelerating wound healing. Here, a multifunctional alginate hydrogel dressing was fabricated using the D-(+)-gluconic acidδ-lactone/CaCO3system. The addition of hyaluronic acid and tannic acid (TA) provides the alginate hydrogel with anti-reactive oxygen species (ROS), hemostatic, and pro-wound healing properties. Notably, soaking the alginate hydrogel in a poly-ϵ-lysine (EPL) aqueous solution enables the alginate hydrogel to be di-crosslinked with EPL through electrostatic interactions, forming a dense network resembling 'armor' on the surface. This simple one-step soaking strategy provides the alginate hydrogel with antibacterial and anti-swelling properties. Swelling tests demonstrated that the cross-sectional area of the fully swollen multifunctional alginate hydrogel was only 1.3 times its initial size, thus preventing excessive wound expansion caused by excessive swelling. After 5 h ofin vitrorelease, only 7% of TA was cumulatively released, indicating a distinctly slow-release behavior. Furthermore, as evidenced by the removal of 2,2-diphenyl-1-picrylhydrazyl free radicals, this integrated alginate hydrogel systems demonstrate a notable capacity to eliminate ROS. Full-thickness skin wound repair experiment and histological analysis of the healing site in mice demonstrate that the developed multifunctional alginate hydrogels have a prominent effect on extracellular matrix formation and promotion of wound closure. Overall, this study introduces a cost-effective and convenient multifunctional hydrogel dressing with high potential for clinical application in treating open wounds.

Bentonite clay reinforced alginate grafted composite hydrogel with remarkable sorptive performance toward removal of methylene green.

The rapid industrial progress in today's world has led to an alarming increase in water pollution caused by various contaminants such as synthetic dyes. To address this issue, a new hydrogel sorbent, BC-r-Na-Alg-g-p(NIPAm-co-AAc), was developed by combining bentonite clay, sodium alginate, and poly(N-isopropyl acrylamide-co-acrylic acid) through one-pot free radical polymerization at 60 °C. The developed sorbent was characterized using several analytical techniques including SEM, FTIR, TGA, UTM, and swelling studies. The swelling capacity of the sorbent was observed to increase remarkably with an increase in pH, reaching a maximum of 9664 % at pH 11. In batch mode sorption experiments, the sorbent's performance toward methylene green (MG) was investigated by analysing the effects of contact time, pH, temperature, and concentration. The experimental data were fitted to pseudo-second-order kinetic and Langmuir isotherm models, indicating chemisorption as the dominant interaction mode between the anionic sorbent and cationic MG. However, physisorption may also occur to a lesser extent, indicated by the significant R2 of the pseudo-first-order kinetic and Freundlich isotherm models. Additionally, the sorbent exhibited very little decrease (approximately 5 %) in sorptive performance for six sorption-desorption cycles. Overall, the facile fabrication, excellent swelling (9664 %), promising sorption performance (2573 mg.g-1), and good recyclability (6 cycles) make the developed sorbent a potential candidate for various industrial applications.

Bide Your Time With Bites: A Case of Rattlesnake Envenomation in Pennsylvania.

This case report represents a 26-year-old male with no significant past medical history who presented to the emergency department in western Pennsylvania following a western diamondback rattlesnake (Crotalus Atrox) bite to his hand. His initial swelling was mild, and his coagulation studies were unremarkable, with minimal changes on repeat studies, and poison control recommended against antivenom administration. He was discharged home with oral antibiotics and analgesics due to his stable clinical course. However, he returned to the emergency department about 12 hours later with worsening pain and swelling that extended to his elbow. He was then given antivenom and transferred to a larger center for higher-level care, ultimately having symptom resolution after further antivenom administration. This report serves to underline the importance of clinician education regarding envenomation management throughout the United States, including areas without indigenous venomous snakes.