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Intra-Abdominal Varix Rupture: A Life-Threatening Cause of Hemoperitoneum

A 54-year-old male with decompensated alcoholic cirrhosis presented after a syncopal event and ground-level fall. Initial examination noted a distended abdomen without overlying bruising. At admission, his hemoglobin was 6.3 g/dL from a baseline of 8-10 g/dL. A computed tomography scan of the abdomen was notable for “complex ascites” adjacent to his liver concerning for […]

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Black flies, also known as buffalo gnats or turkey gnats, are blood-feeding insects in the insect family simuliidae. Immature black flies breed in fast-flowing water, from which the adults emerge in great swarms (usually) in spring or early summer. Black flies are notorious nuisance pests in certain parts of the world and are vectors of the agent of onchocerciasis in tropical areas. Nuisance biting alone can be serious, even fatal, with many reports of livestock and poultry deaths due to black fly biting.1, 2, 3 Outbreaks were a major problem in the southern United States during the early 20th century1 but disappeared until recently. This reemergence may be due to the elimination of harsh pesticides and the cleaning up of creeks and rivers.

Black fly bite reactions include papules, erythematous wheals, indurations, or extensive swelling of the affected area.4 In addition, adenopathy (black fly stiff neck) may occur from bites on the face, neck, and scalp.2 There are many reports of reactions to black fly biting in the northern United States and other parts of the world,2,5, 6, 7 but none from the southern United States, where black flies have typically not been a problem. Here we carefully document the timeline of bites and subsequent development of cutaneous lesions in an entomologist who was investigating a black fly outbreak along the Pearl River in central Mississippi during the spring of 2018.

Methods
The entomologist bitten by black flies was examined by the second author and bite reactions were described and photographed over the following 72 hours. Samples of the offending insect were collected and identified as Simuliim meridionale.

Results
From March 26 to April 2, at least 10 black fly bites were noted on the patient's arms, neck, and face. Bite reactions sometimes developed into large indurations by 48 hours (Figure 1). Two bites on the neck were carefully followed for 48 hours (Figure 2). At first, there was nothing but erythema and a small hemorrhagic center. Four hours later, lesions developed into a central wheal with surrounding erythema. The diagnosis was papular urticaria, presumably resulting from hypersensitivity to black fly salivary proteins. A raised urticarial papule developed at each bite site with surrounding erythema that itched intensely. Over the course of 24 hours, the urticarial lesions resolved, leaving only an erythematous flattened lesion. By 48 hours, the lesions had completely faded.

Development and Resolution of Cutaneous Lesions Caused by Black Fly Bites (Diptera: Simuliidae)

Black flies, also known as buffalo gnats or turkey gnats, are blood-feeding insects in the insect family simuliidae. Immature black flies breed in fast-flowing water, from which the adults emerge in great swarms (usually) in spring or early summer. Black flies are notorious nuisance pests in certain parts of the world and are vectors of […]

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National and Regional Trends in Deep Vein Thrombosis Hospitalization Rates, Discharge Disposition, and Outcomes for Medicare Beneficiaries

Older adults are at increased risk of developing deep vein thrombosis. Little is known about national trends of deep vein thrombosis hospitalizations in the context of primary and secondary prevention efforts. Methods Medicare standard analytic files were analyzed from 2015-2017 to identify Fee-For-Service patients aged ≥65 years who had a principal discharge diagnosis for deep […]

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Computed tomography of the chest. (A) Before treatment, with right pulmonary infiltrates. (B) After 1 year of itraconazole, with marked improvement.

Sickle Cough: A Case of Nonresolving Pneumonia

A 26-year-old female graduate student with sickle-cell disease presented with fever, dyspnea, and right shoulder pain. Computed tomography of the chest demonstrated right middle and lower lobe infiltrates (Figure, A). She was diagnosed with pneumonia, acute chest syndrome, and vaso-occlusive crisis and prescribed 5 days of amoxicillin-clavulanic acid.   She was readmitted 1 month later […]

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Twenty-Five-Year (1986-2011) Trends in the Incidence and Death Rates of Stroke Complicating Acute Myocardial Infarction

The occurrence of a stroke after an acute myocardial infarction is associated with increased morbidity and mortality rates. However, limited data are available, particularly from a population-based perspective, about recent trends in the incidence and mortality rates associated with stroke complicating an acute myocardial infarction. The purpose of this study was to examine 25-year trends […]

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Effectiveness and Safety of Rivaroxaban Versus Warfarin in Frail Patients with Venous Thromboembolism (video)

Frailty predicts poorer outcomes in patients receiving anticoagulation. We assessed the effectiveness and safety of rivaroxaban vs warfarin in frail patients experiencing venous thromboembolism. Methods Using US MarketScan claims data from January 2012-December 2016, we identified frail patients (using the Johns Hopkins Claims-Based Frailty Indicator score) who had ≥1 primary hospitalization/emergency department visit diagnosis codes […]

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