Lameness

跛行
  • 文章类型: Journal Article
    目的:为了描述诊断,管理,以及一只狗的右远端桡骨骨软骨瘤穿透尺骨的结果,导致膨胀性溶解和骨折。
    方法:一个9个月大的全雌性德国短剑指针。
    这只狗有2个月的右前肢负重跛行史和2周的逐渐扩大史,前臂上的前外侧有坚硬的肿胀。计算机断层扫描用于表征病变和手术计划。
    结果:尺骨远端切除了受影响的尺骨段,放射状骨软骨瘤切除。狗在术后2、16和45周声音良好。45周时的放射学照片显示,尺骨切除间隙持续存在,放射状骨软骨瘤切除部位边缘不规则但边缘光滑,局灶性皮质不规则。没有骨软骨瘤复发的证据。
    结论:这是新认识到的一种骨软骨瘤穿透狗相邻骨的皮质,导致扩张性松解和皮质骨折。计算机断层扫描在诊断和手术计划中很重要,手术治疗成功切除骨软骨瘤和尺骨病变。该病例提供了骨软骨瘤切除术后的长期影像学和临床随访,并有助于对狗骨软骨瘤切除术后的预后了解。
    OBJECTIVE: To describe the diagnosis, management, and outcome of a dog with a right distal radial osteochondroma that penetrated the ulna, causing expansile lysis and fracture.
    METHODS: A 9-month-old entire female German Shorthaired Pointer.
    UNASSIGNED: The dog had a 2-month history of weight-bearing lameness of the right forelimb and a 2-week history of a progressively enlarging, firm swelling on the distolateral antebrachium. Computed tomography was used to characterize the lesion and for surgical planning.
    RESULTS: A distal ulnar ostectomy removed the affected ulnar segment, and the radial osteochondroma was excised with rongeurs. The dog was sound at 2, 16, and 45 weeks postoperatively. Radiographs at 45 weeks showed a persistent ulnar ostectomy gap with irregular but smoothly marginated edges and focal cortical irregularity at the site of radial osteochondroma excision. There was no evidence of osteochondroma recurrence.
    CONCLUSIONS: This is a newly recognized presentation of an osteochondroma penetrating the cortex of an adjacent bone in a dog resulting in expansile lysis and cortical fracture. Computed tomography was important in diagnosis and surgical planning, and surgical treatment was successful in removing the osteochondroma and ulnar lesion. This case provides long-term radiographic and clinical follow-up after osteochondroma excision and contributes to the current knowledge on prognosis following osteochondroma excision in dogs.
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  • 文章类型: Journal Article
    爪病变显著导致跛行,极大地影响了母猪的福利。这项研究调查了影响巴西商业牧群母猪爪病变严重程度的不同因素。
    总共129只母猪(n=12,364只母猪)被纳入研究。牧群在中西部,东南,或巴西南部地区。库存规模分为250-810头母猪,811-1,300头母猪,1,301-3,000头母猪,和3,001-10,000头母猪。牧群属于合作社(Coop),积分器,或独立的结构。牧群管理是在现场(内部)维持品种,或通过购买商业遗传学(外部)。牛群在妊娠期间采用了单个板条箱或集体住房。在每个农场里,一组随机选择的母猪由同一评估者(两名独立专家评估了129群)从0(无)到3(严重)的脚跟过度生长和侵蚀(HOE)进行评分,鞋跟-鞋底裂纹(HSC),沿白线(WL)的分离,水平(CHW)和垂直(CVW)墙体裂缝,和杂草丛生的脚趾(T),或产后后腿的露爪(DC)。该研究使用主成分分析(PCA)和层次聚集聚类(HAC)分析评估了牛群之间的差异和相似性。因素的影响(即,生产结构,管理,怀孕期间的住房,和区域)使用偏最小二乘法(PLS)进行评估。
    脚跟过度生长和侵蚀的患病率最高,其次是WL和CHW,而T的得分最低,DC,CVW。牧群分为三个集群(即,C1、C2和C3)。鞋跟过度生长和侵蚀,HSC,WL,CHW,CVW,T分别减少了17、25、11、25、21和17%,分别,在C3中与C1和2的组合相比。独立结构增加了所有三个集群中的L指数。此外,个人住房增加了L指数,而与集群无关。结果表明,向更大的方向转变,更多技术先进的牛群可能有利于爪子的健康。此外,采用集体妊娠住房似乎可以减轻对爪子健康的不利影响,尽管需要进一步验证,因为巴西最近才从个人住房做法过渡。
    UNASSIGNED: Claw lesions significantly contribute to lameness, greatly affecting sow welfare. This study investigated different factors that would impact the severity of claw lesions in the sows of Brazilian commercial herds.
    UNASSIGNED: A total of 129 herds (n = 12,364 sows) were included in the study. Herds were in the Midwest, Southeast, or South regions of Brazil. Inventory sizes were stratified into 250-810 sows, 811-1,300 sows, 1,301-3,000 sows, and 3,001-10,000 sows. Herds belonged to Cooperative (Coop), Integrator, or Independent structures. The herd management was conducted either maintaining breeds from stock on-site (internal), or through purchase of commercially available genetics (external). Herds adopted either individual crates or group housing during gestation. Within each farm, one randomly selected group of sows was scored by the same evaluator (two independent experts evaluated a total of 129 herds) from 0 (none) to 3 (severe) for heel overgrowth and erosion (HOE), heel-sole crack (HSC), separation along the white line (WL), horizontal (CHW) and vertical (CVW) wall cracks, and overgrown toes (T), or dewclaws (DC) in the hind legs after parturition. The study assessed differences and similarities between herds using Principal Component Analysis (PCA) and Hierarchical Agglomerative Clustering (HAC) analysis. The effects of factors (i.e., production structure, management, housing during gestation, and region) were assessed using the partial least squares method (PLS).
    UNASSIGNED: Heel overgrowth and erosion had the highest prevalence, followed by WL and CHW, while the lowest scores were observed for T, DC, and CVW. Herds were grouped in three clusters (i.e., C1, C2, and C3). Heel overgrowth and erosion, HSC, WL, CHW, CVW, and T were decreased by 17, 25, 11, 25, 21, and 17%, respectively, in C3 compared to C1 and 2 combined. Independent structure increased the L-Index in all three clusters. Furthermore, individual housing increased the L-Index regardless of the cluster. The results suggest that shifting toward larger, more technologically advanced herds could potentially benefit claw health. Additionally, adopting group gestation housing appears to mitigate the adverse effects on claw health, although further validation is necessary, as Brazil has only recently transitioned from individual housing practices.
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  • 文章类型: Journal Article
    背景:行走能力是肉鸡福利的一个非常重要的基于动物的指标,需要在整个商业生产中进行监测。
    方法:对现有评估肉鸡行走能力的方法的技术和科学文献进行了综述,和可靠性,当相关信息可用时,评估不同方法的有效性和可行性.
    结果:视觉步态评分具有很高的有效性,设备需求最少,执行速度相对较快;然而,这种方法是主观的,需要广泛的培训。由于这个原因,更客观的测试,比如撒谎测试的延迟,已经开发,尽管需要对这些测试进行更多验证。其他确定的方法,如障碍课程,旋转杆测试以及动力学和运动学方法,需要大量的设备,使它们在农场检查时不切实际。依赖于运动或活动数据的自动化方法具有未来发展的潜力,但目前缺乏传统步态评分的分辨率,并且需要相机或加速度计等设备。
    结论:目标,看似有效,存在可重复和可行的选择来评估行走能力,这将有助于监测商业肉鸡福利;然而,需要对这些方法进行更多验证,尤其是在商业农场环境中。
    BACKGROUND: Walking ability is a highly important animal-based indicator of welfare in broilers that warrants monitoring across commercial production.
    METHODS: A review of the technical and scientific literature on existing methods for assessing walking ability in broilers was conducted, and the reliability, validity and feasibility of the different methods were assessed when relevant information was available.
    RESULTS: Visual gait scoring has high validity, minimal equipment needs and is relatively quick to perform; however, this method is subjective and requires extensive training. Due to this, more objective tests, such as the latency to lie test, have been developed, although more validation of these tests is required. Other identified methods, such as obstacle courses, the rotarod test and kinetic and kinematic approaches, require considerable amounts of equipment, making them impractical for use during on-farm inspections. Automated methods that rely on movement or activity data have potential for future development but currently lack the resolution of traditional gait scoring and require equipment such as cameras or accelerometers.
    CONCLUSIONS: Objective, seemingly valid, repeatable and feasible options exist for the assessment of walking ability that would facilitate the monitoring of commercial broiler welfare; however, more validation of these methods is required, especially in commercial farm settings.
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  • 文章类型: Case Reports
    一只9岁的雄性cast割家养短毛猫有2周的急性病史,进行性左骨盆肢体跛行。步态评估显示3/5级左骨盆肢体跛行,根据骨科检查或X光片,没有明显的骨科原因。其他神经系统检查正常。MRI显示左侧L6-7极外侧椎间盘挤压,可能伴有L6脊神经的继发性神经炎。进行左侧L6-7椎间孔切开术以去除挤压的椎间盘材料,并为明显扩大的神经根提供额外的空间。还进行了L6-7开窗。术后26天,患者恢复良好,跛行几乎完全消退。
    该病例报告有助于越来越多的关于外侧椎间盘挤压作为猫骨盆肢体跛行的病因的文献,特别是当没有神经缺陷时。此外,该病例报告强调了横断面高级成像对无法确定骨科或影像学原因的跛行猫的诊断效用。最后,该病例强调了手术干预作为治疗猫的一种选择的有效性,该猫患有腰椎远外侧椎间盘突出症,仅通过医疗管理就无法改善。这一发现可能对具有类似发现的猫的未来手术方法产生影响。
    UNASSIGNED: A 9-year-old male castrated domestic shorthair cat was presented with a 2-week history of acute, progressive left pelvic limb lameness. Gait evaluation revealed a grade 3/5 left pelvic limb lameness with no apparent orthopedic cause for the lameness based on orthopedic examination or radiographs. The neurological examination was otherwise normal. MRI revealed a left-sided L6-7 far lateral intervertebral disc extrusion with possible secondary neuritis of the L6 spinal nerve. A left-sided L6-7 foraminotomy was performed to remove the extruded disc material and provide additional space for the significantly enlarged nerve root. An L6-7 fenestration was also performed. The patient made an excellent recovery with near-complete resolution of lameness at 26 days postoperatively.
    UNASSIGNED: This case report contributes to the growing body of literature on lateral intervertebral disc extrusion as an etiological factor in pelvic limb lameness in cats, particularly when neurological deficits are absent. Furthermore, the case report highlights the diagnostic utility of cross-sectional advanced imaging for cats with lameness for which an orthopedic or radiographic cause cannot be identified. Finally, this case underscores the efficacy of surgical intervention as a treatment option for cats with lumbar far lateral intervertebral disc extrusions that do not improve with medical management alone. This finding could have implications for future surgical approaches in cats with similar findings.
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  • 文章类型: Journal Article
    奶牛的跛行是由影响动物福利的多种疾病引起的临床体征。这项研究的目的是评估农场管理者之间跛行患病率估计的一致性和由训练有素的观察员进行的运动评分,在密闭和放牧的乳制品系统中。这项研究是在阿根廷的18个奶牛场进行的。经过训练的观察者使用从0到3的四点视觉量表对泌乳母牛的运动进行评分。农场经理接受了关于牧群中跛脚母牛数量的采访。通过计算林的一致性和相关系数来评估农场经理和观察者检测到的跛行患病率的一致性。使用广义混合模型分析了放牧系统与受限系统在跛行患病率上的比较,假设错误是二项分布。平均而言,与受过训练的观察者相比,农场经理估计跛行的患病率较低(p<0.01);2.24%和7.06%,分别。根据训练有素的观察者的估计,我们无法检测到禁闭系统和放牧系统之间跛行患病率的差异(p=0.19)。
    Lameness in dairy cows is a clinical sign resulting from multiple diseases that affects animal welfare. The aim of this study was to evaluate the consistency of lameness prevalence estimations between farm managers and locomotion scoring conducted by trained observers, in confined and grazing dairy systems. The study was conducted on 18 dairy farms in Argentina. The locomotion of the lactating cows was scored by trained observers using a four-point visual scale from 0 to 3. Farm managers were interviewed about the number of lame cows in the herd. The consistency of lameness prevalence detected by the farm manager and the observers was assessed by computing the Lin\'s concordance and correlation coefficient. The comparison of grazing systems versus confined systems on lameness prevalence was analyzed using a generalized mixed model, assuming a binomial distribution for the errors. On average, farm managers estimated a lower prevalence of lameness (p < 0.01) compared with the trained observers; 2.24% and 7.06%, respectively. Based on the estimations from trained observers, we could not detect differences (p = 0.19) in lameness prevalence between confined and grazing systems.
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  • 文章类型: Journal Article
    自2004年以来,随着农民采用基于证据的管理方法来控制跛行,英格兰绵羊群中跛行的患病率有所降低。2011年,农场动物福利委员会提出了到2021年绵羊跛行率<2%的目标。这项研究调查了该目标是否已实现,并确定了哪些做法与跛行患病率相关。在2022年,向1000名随机选择的农民发送了邮政问卷,以调查跛行和管理实践的患病率。母羊和羔羊跛行的几何平均患病率<2%,但中位数为3%;约26%的羊群跛行<2%。使用具有多变量线性模型的稳健变量选择来分析数据。隔离母羊≥3周并且不使用足浴或足部修剪以防止跛行的农民的跛行患病率比不使用这些做法的农民低40-50%。更少的农民(19.0%)总是使用肠胃外抗菌药物来治疗脚病,一个有效的做法,比以前的研究(49.7%)。我们得出的结论是,26%的农民已经实现了英格兰跛行<2%的目标,需要进一步的工作,让更多的农民遵循循证管理实践,以最大限度地减少跛行。
    Since 2004, the prevalence of lameness in sheep flocks in England has reduced as farmers have adopted evidence-based management practices to control lameness. In 2011, the Farm Animal Welfare Council proposed a target prevalence of <2% lameness in sheep by 2021. This study investigated whether that target had been achieved and determined which practices were associated with prevalence of lameness. A postal questionnaire was sent to 1000 randomly selected farmers to investigate the prevalence of lameness and management practices in 2022. The geometric mean prevalence of lameness was <2% in ewes and lambs, but the median was 3%; approximately 26% flocks had <2% lameness. Data were analysed using robust variable selection with multivariable linear models. Farmers that quarantined ewes for ≥3 weeks and did not use foot bathing or foot trimming to prevent lameness had 40-50% lower prevalence of lameness than those not using these practices. Fewer farmers (19.0%) were always using parenteral antimicrobials to treat footrot, an effective practice, than in previous research (49.7%). We conclude that the target of <2% lameness in England has been achieved by 26% of farmers, and further work is required for more farmers to follow the evidence-based management practices to minimise lameness.
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  • 文章类型: Journal Article
    这项研究的目的是通过进行途径分析来确定先前确定为跛行预测因子的高置信度代谢物,并了解其生物学相关性。对于奶牛行业来说,跛行是一项重大挑战,对动物福利和农场经济产生重大影响。在出现临床体征之前,了解与跛行相关的过渡期代谢变化可能有助于其早期发现和风险预防。具有高置信度的代谢物预测因子的注释以及对代谢与免疫之间相互作用的理解对于更好地理解这种情况至关重要。使用具有真实标准的液相色谱-串联质谱(LC-MS/MS)来提高对先前确定的代谢产物的推定注释的信心,这些代谢产物可预测过渡奶牛的跛行,有可能识别甲酚,丙戊酸,和葡萄糖酸内酯分别为L1,L2和L1,它们是鉴定的最高置信水平。涉及跛行预测因子的生物途径的代谢物集富集分析鉴定出6个显著途径(p<0.05)。相比之下,过度表达分析和拓扑分析确定了两条显著的途径(p<0.05)。总的来说,我们的LC-MS/MS分析被证明足以自信地鉴定先前发现可预测跛行的尿液样本中的代谢物,并了解它们潜在的生物学相关性,尽管在进行非靶向代谢组学时存在代谢物鉴定和通路分析的挑战。这种方法显示出作为识别生物标志物的可靠方法的潜力,这些生物标志物可以在将来用于预测产卵前的跛行风险。需要使用更大的队列进行验证,以评估这些发现的概括。
    The aim of this study was to identify with a high level of confidence metabolites previously identified as predictors of lameness and understand their biological relevance by carrying out pathway analyses. For the dairy cattle sector, lameness is a major challenge with a large impact on animal welfare and farm economics. Understanding metabolic alterations during the transition period associated with lameness before the appearance of clinical signs may allow its early detection and risk prevention. The annotation with high confidence of metabolite predictors of lameness and the understanding of interactions between metabolism and immunity are crucial for a better understanding of this condition. Using liquid chromatography-tandem mass spectrometry (LC-MS/MS) with authentic standards to increase confidence in the putative annotations of metabolites previously determined as predictive for lameness in transition dairy cows, it was possible to identify cresol, valproic acid, and gluconolactone as L1, L2, and L1, respectively which are the highest levels of confidence in identification. The metabolite set enrichment analysis of biological pathways in which predictors of lameness are involved identified six significant pathways (p < 0.05). In comparison, over-representation analysis and topology analysis identified two significant pathways (p < 0.05). Overall, our LC-MS/MS analysis proved to be adequate to confidently identify metabolites in urine samples previously found to be predictive of lameness, and understand their potential biological relevance, despite the challenges of metabolite identification and pathway analysis when performing untargeted metabolomics. This approach shows potential as a reliable method to identify biomarkers that can be used in the future to predict the risk of lameness before calving. Validation with a larger cohort is required to assess the generalization of these findings.
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  • 文章类型: Journal Article
    背景:犬股股关节骨关节炎是一种常见的,痛苦和衰弱的状况。这项研究的目的是评估在使用脉冲电磁场疗法进行单次治疗后,该患者组是否立即发生了任何可测量的疼痛或跛行变化。前瞻性招募了八只表现出疼痛和跛行迹象的股股关节骨关节炎的狗,控制,双盲,交叉研究。受试者两次参加研究机构,接受脉冲电磁场治疗的一种主动治疗和一种安慰剂治疗。使用赫尔辛基慢性疼痛指数和视觉模拟量表主观测量一种脉冲电磁场治疗对疼痛和跛行的直接影响,并使用压敏人行道客观地测量。
    结果:在脉冲电磁场治疗的活性和安慰剂治疗中,受试者患肢步幅的变化具有统计学上的显著差异(P=0.03)。在积极的治疗结果中,在治疗后,受影响的肢体的距离(P=0.04)和步幅(P=0.047)的测量值有统计学上的显着变化。对于主观结果衡量标准,在治疗当天晚上或第二天早晨,活性治疗和安慰剂治疗与治疗前值无统计学显著差异.在安慰剂治疗结果中,在治疗前和下一个早晨值之间的视觉模拟评分(P=0.03)中检测到统计学上显著的变化(改善)。
    结论:这项研究的结果没有显示,在单次应用脉冲电磁场治疗后,所有者评估的疼痛水平或时空表现的改善。
    BACKGROUND: Canine coxofemoral joint osteoarthritis is a common, painful and debilitating condition. The objective of this study was to evaluate if any measurable changes in pain or lameness occurred in this patient group immediately after a single treatment with pulsed electromagnetic field therapy. Eight dogs with coxofemoral joint osteoarthritis presenting with signs of pain and lameness were prospectively recruited to this randomised, controlled, double blinded, cross-over study. Subjects attended the research facility on two occasions for one active and one placebo treatment with pulsed electromagnetic field therapy. The immediate effect of one pulsed electromagnetic field therapy treatment on pain and lameness was measured subjectively with the Helsinki Chronic Pain Index and Visual Analogue Scale and objectively using a pressure sensitive walkway.
    RESULTS: A statistically significant difference (P = 0.03) for change in stride length in the affected limb was recorded for subjects between the active and placebo treatments with pulsed electromagnetic field therapy. Within the active treatment results, there was a statistically significant change in the measurement for reach (P = 0.04) and stride length (P = 0.047) which got shorter in the affected limb post treatment. For the subjective outcome measures, there was no statistically significant difference between the active and placebo treatments for the evening of the treatment day or the next morning from pre-treatment values. Within the placebo treatment results a statistically significant change (improvement) was detected in Visual Analogue Score (P = 0.03) between pre-treatment and the next morning values.
    CONCLUSIONS: The findings of this study do not show demonstrable improvement in owner assessed pain levels or temporospatial performance in dogs with coxofemoral joint osteoarthritis immediately after a single application of pulsed electromagnetic field therapy.
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  • 文章类型: Journal Article
    为了确定使用红外热成像(IRT)预防奶牛跛行的可能性,这项研究的目的是评估温度变化取决于病变的存在,测量点和腿的位置。该研究使用了来自60头荷斯坦奶牛的约3.000IRT记录,这些奶牛饲养在一个自由摊位的谷仓中。在蹄的两个区域进行表面温度测量:冠状带的区域,和冠状带上方2厘米的皮肤区域。在两个测量点处,在健康腿和患病腿之间观察到温度的高度显著差异(P=0.004;0.006,P<0.01)。此外,两个测量点的前腿和后腿之间的温度值有显著差异(P=0.029;0.037;0.045;0.012;0.018,P<0.05)或高度显著差异(P=0.004;0.006,P<0.01),即,冠状带和皮肤.尽管证实了红外热成像在检测跛行中的潜在适用性,考虑环境因素的重大影响至关重要,杂质,和动物相关因素。
    In order to determine the possibility of using infrared thermography (IRT) in preventing lameness in dairy cows, the aim of this study was to evaluate temperature variations depending on the lesion presence, measurement points and leg position. The study used about 3 000 IRT records from 60 Holstein cows housed in a free-stall barn. Surface temperature measurements were taken at two regions of the hooves: the region of the coronary band, and the region of the skin up to 2 cm above the coronary band. A highly significant (P = 0.004; 0.006, P < 0.01) difference in temperature was observed between healthy and diseased legs at both measurement points. Additionally, a significant (P = 0.029; 0.037; 0.045; 0.012; 0.018, P < 0.05) or highly significant (P = 0.004; 0.006, P < 0.01) difference in temperature values between the front and rear legs was established for both measurement points, i.e., the coronary band and the skin. Despite confirming the potential applicability of infrared thermography in the detection of lameness, it is crucial to consider the significant influences of the environmental factors, impurities, and animal-related factors.
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  • 文章类型: Journal Article
    传染性羊指皮炎(CODD)导致严重的,传染性脚病和绵羊跛行,在英国很常见,现在也在其他国家出现。除了造成严重的动物福利问题,由于体重减轻/体重增加不足,这种疾病会造成巨大的经济损失,兽医治疗。测量CODD病变进展,评分系统从1(早期病变)到5(治愈)。这里,使用自然感染的实验羊群的样本,样本取自CODD5期病变,后处理,并使用先前公开的方法进行细菌分离和MLST。将序列与同一群人的序列进行了比较,和以前的研究。所有CODD5病变均产生活的密螺旋体。细菌。观察到高水平的细菌变异,具有12种序列类型(STs)的T.medium系统组(11种新),15个T.phagedenis系统组STs(9个新)和6个T.pedisSTs,其中两个是新的。这项研究表明,CODD5期病变仍含有活细菌,代表所有三种已知的致病性密螺旋体。系统组,因此,这些可能在疾病传播和流行病学中起作用,尽管治疗后出现治愈。从不同来源购买绵羊的受感染羊群中的高水平CODD螺旋体变异性,正如常见的农业实践中可能发生的那样,可能会提出细菌性疾病难以治疗的原因,控制和根除,并进一步增加了这些病变的多细菌发病机制的复杂性。
    Contagious ovine digital dermatitis (CODD) causes a severe, infectious foot disease and lameness of sheep, is common within the UK and is now also emerging in other countries. As well as causing severe animal welfare issues, huge economic losses emerge from the disease due to weight loss/lack of weight gain, and veterinary treatments. CODD lesion progress is measured, with a scoring system from 1 (early lesions) to 5 (healed). Here, using samples from an experimental flock infected by natural means, samples were taken from CODD stage 5 lesions, post treatment, and subjected to bacterial isolation and MLST using previously published methods. Sequences were compared to others from the same flock, and those from previous studies. All CODD 5 lesions produced viable Treponema spp. bacteria. High levels of variation of bacteria were seen, with 12 sequence types (STs) for T. medium phylogroup (11 new), 15 STs for T. phagedenis phylogroup (9 new) and six T. pedis STs, of which two were new. This study shows that CODD stage 5 lesions still contain viable bacteria, representing all three known pathogenic Treponema spp. phylogroups, and these may thus play a role in disease transmission and epidemiology despite appearing healed after treatment. The high level CODD treponeme variability within an infected flock where sheep were bought from different sources, as might occur in common agricultural practice, may suggest reasons as to why the bacterial disease is difficult to treat, control and eradicate, and adds further complexity to the polybacterial pathogenesis of these lesions.
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