Analyze Diet

Topic:Necropsy

Necropsy, also known as an autopsy, is a systematic examination of a horse's body after death to determine the cause of death and evaluate any disease or injury. This procedure involves a thorough assessment of the horse's organs and tissues, often including histopathological analysis to identify abnormalities at the microscopic level. Necropsy can provide valuable insights into equine health issues, contributing to a better understanding of disease processes, management practices, and potential preventive measures. This page compiles peer-reviewed research studies and scholarly articles that explore the methodologies, findings, and implications of necropsy in equine veterinary science.
Infection of an equine placenta with a novel mycobacterial species leading to abortion. Johnson AK, Roberts JF, Hagan A, Wilborn RR, Dujovne G, Sells SF, Donahue JM.A 25-year-old pregnant American Quarter Horse mare presented with a 1-week history of progressively worsening vaginal discharge. Transrectal ultrasound revealed increased thickness of the combined uterus and placenta with evidence of chorioallantoic edema but no placental separation. A thickened amnion was visible on transabdominal ultrasound. Abortion occurred 2 days after presentation despite medical treatment. At necropsy, the chorioallantois had variable but diffuse thickening with focally extensive browning of the chorionic surface in the right horn and adjacent body. There were fluid-fil...
Clinicopathologic observations on laryngoplasty failure in a horse.
Veterinary surgery : VS    April 30, 2012   Volume 41, Issue 5 649-653 doi: 10.1111/j.1532-950X.2012.00975.x
Hardcastle MR, Pauwels FE, Collett MG.To report morphologic findings associated with laryngoplasty failure in a horse. Methods: Clinical report. Methods: A 9-year-old Thoroughbred cross gelding. Methods: Necropsy and histopathology were performed on a horse that died peracutely during anesthetic recovery after correction of a right dorsal displacement of the ascending colon. Three weeks earlier the horse had left laryngoplasty and ventriculocordectomy. Results: Dissection of the larynx revealed that the laryngoplasty suture had pulled through the muscular process of the left arytenoid cartilage, which appeared grossly normal. Hist...
Poisoning by Indigofera lespedezioides in horses.
Toxicon : official journal of the International Society on Toxinology    April 25, 2012   Volume 60, Issue 3 324-328 doi: 10.1016/j.toxicon.2012.04.341
Lima EF, Riet-Correa F, Gardner DR, Barros SS, Medeiros RM, Soares MP, Riet-Correa G.Poisoning by Indigofera lespedezioides is reported in horses in the state of Roraima, northern Brazil. The main clinical signs are anorexia, sleepiness, unsteady gait, severe ataxia, weakness, stumbling, and progressive weight loss. To induce the disease experimentally, a 7-year-old horse was introduced in a small paddock invaded by the plant. The first nervous signs were observed 44 days from the start of grazing. The animal was euthanized on day 59. No significant gross lesions were observed upon necropsies of the experimental horse as well as one spontaneously affected horse. Upon histologi...
The use of magnetic resonance imaging in evaluating horses with spinal ataxia. Mitchell CW, Nykamp SG, Foster R, Cruz R, Montieth G.To determine the accuracy of magnetic resonance imaging for diagnosing cervical stenotic myelopathy in horses, 39 horses with spinal ataxia and 20 control horses underwent clinical and neurologic examinations, cervical radiographs, euthanasia, magnetic resonance (MR) imaging of the cervical spine and necropsy. Twenty-four horses were diagnosed with cervical stenotic myelopathy, 5 with cervical vertebral stenosis, 7 with idiopathic ataxia, 3 horses had other causes of ataxia, and 20 were controls. The MR images were assessed for spinal cord intensity changes, presence of spinal cord compression...
An outbreak of equine botulism type A associated with feeding grass clippings. Ostrowski SR, Kubiski SV, Palmero J, Reilly CM, Higgins JK, Cook-Cronin S, Tawde SN, Crossley BM, Yant P, Cazarez R, Uzal FA.In September 2010, an outbreak of type A botulism involved 4 horses in northern California that were fed grass clippings obtained from a nearby park. All 4 animals developed a progressive flaccid paralysis syndrome clinically consistent with exposure to preformed Clostridium botulinum neurotoxin (BoNT). Within 48 hr of consuming the grass clippings, all 4 horses showed marked cervical weakness (inability to raise their heads to a normal position) and died or were euthanized within 96 hr. One horse was submitted for diagnostic examination and subsequent necropsy. At necropsy, extensive edema wa...
Clinical, pathological, and genetic characterization of Listeria monocytogenes causing sepsis and necrotizing typhlocolitis and hepatitis in a foal. Warner SL, Boggs J, Lee JK, Reddy S, Banes M, Cooley J.Listeria monocytogenes was isolated from the blood, lungs, and liver of a 5-week-old American Quarter Horse filly that presented with a 2-day history of fever, lethargy, ataxia, and seizure activity. The foal was born on a well-managed breeding facility to a multiparous mare with no periparturient complications. At 8 hr of age, the foal had an adequate passive transfer of immunity (immunoglobulin G > 2,000 mg/dl). Since the time of birth, the foal reportedly had mild, intermittent diarrhea that responded to gastrointestinal protectants and probiotics. Despite prompt and aggressive treatment af...
Acute and long-term cardiomyopathy and delayed neurotoxicity after accidental lasalocid poisoning in horses.
Journal of veterinary internal medicine    April 21, 2012   Volume 26, Issue 4 1005-1011 doi: 10.1111/j.1939-1676.2012.00933.x
Decloedt A, Verheyen T, De Clercq D, Sys S, Vercauteren G, Ducatelle R, Delahaut P, van Loon G.Horses are extremely susceptible to ionophore intoxication. Although numerous reports are available regarding monensin, little is known about lasalocid toxicity. Objective: To describe accidental lasalocid poisoning on a farm in Belgium. Methods: Eighty-one horses, of which 14 demonstrated clinical signs from day 0-21 after being fed a new concentrate batch. One horse died on day 20 and another on day 27. Methods: The most severe cases (n = 7), admitted to the clinic on day 29-46, underwent cardiac examination and blood biochemical analysis, including determination of plasma cardiac troponin...
Nigropallidal encephalomalacia in horses grazing Rhaponticum repens (creeping knapweed).
Australian veterinary journal    March 27, 2012   Volume 90, Issue 4 151-154 doi: 10.1111/j.1751-0813.2011.00879.x
Elliott CR, McCowan CI.Nigropallidal encephalomalacia was diagnosed in two horses in northern Victoria that had a history of long-term pasture access to a dense growth of Rhaponticum repens. The region in which the affected horses lived had received well above average rainfall for several months preceding the poisoning. Affected horses had sudden onset of subcutaneous oedema of the head, impaired prehension and mastication, dullness, lethargy and repeated chewing-like jaw movements. Diagnosis was confirmed at necropsy, with characteristic malacic lesions in the substantia nigra and globus pallidus of the brain. This...
Prevalence of latent alpha-herpesviruses in Thoroughbred racing horses.
Veterinary journal (London, England : 1997)    March 10, 2012   Volume 193, Issue 2 579-582 doi: 10.1016/j.tvjl.2012.01.030
Pusterla N, Mapes S, David Wilson W.The objective of this study was to detect and characterize latent equine herpes virus (EHV)-1 and -4 from the submandibular (SMLN) and bronchial lymph (BLN) nodes, as well as from the trigeminal ganglia (TG) of 70 racing Thoroughbred horses submitted for necropsy following sustaining serious musculoskeletal injuries while racing. A combination of nucleic acid precipitation and pre-amplification steps was used to increase analytical sensitivity. Tissues were deemed positive for latent EHV-1 and/or -4 infection when found PCR positive for the corresponding glycoprotein B (gB) gene in the absence...
Molecular and pathological investigations of EHV-1 and EHV-4 infections in horses in Turkey.
Research in veterinary science    March 7, 2012   Volume 93, Issue 3 1504-1507 doi: 10.1016/j.rvsc.2012.01.019
Turan N, Yildirim F, Altan E, Sennazli G, Gurel A, Diallo I, Yilmaz H.The aim of the present study was to investigate abortion storms that occurred in the Marmara region of Turkey in 2008-2009 using a real-time PCR. Two aborted foetuses were necropsied and histo-pathological findings reported herein. Ten lungs, 3 brains and one nasal swab from 10 aborted foetuses, 6 nasal swabs and 3 vaginal swabs from aborting mares were included in this study. EHV-1 was isolated from the lung, liver and brain of 1 aborted foetus. EHV-1 DNA was detected in the lungs, livers and spleens of 2 necropsied foetuses and in 3 lungs from 10 foetuses submitted for diagnosis. A brain fro...
Meningitis and meningoencephalomyelitis in horses: 28 cases (1985-2010).
Journal of the American Veterinary Medical Association    February 16, 2012   Volume 240, Issue 5 580-587 doi: 10.2460/javma.240.5.580
Toth B, Aleman M, Nogradi N, Madigan JE.To describe clinical and clinicopathologic findings and outcome of horses with meningitis and meningoencephalomyelitis. Methods: Retrospective case series. Methods: 28 horses. Methods: Medical records of horses admitted to the hospital during a 25-year period were reviewed. Horses with a definitive diagnosis of meningitis or meningoencephalomyelitis were included in this study. Information extracted from the medical records included signalment, history, reason for admission, clinical signs, results of clinicopathologic testing and diagnostic procedures, treatment, outcome, and necropsy finding...
Cranial mediastinal liposarcoma in a horse.
Veterinary pathology    January 27, 2012   Volume 49, Issue 6 1040-1042 doi: 10.1177/0300985811432348
Kondo H, Wickins SC, Conway JA, Mallicote MF, Sanchez LC, Agnew DW, Farina LL, Abbott JR.A 23-year-old Anglo-Arabian mare was presented with tachypnea, dyspnea, and pitting edema of the ventral thoracic subcutis. On necropsy, a tan to red, friable, irregularly shaped mass (23 × 20 × 18 cm) occupied the cranial mediastinum. Histologically, the mass was classified as a liposarcoma and was composed of short interlacing bundles of spindle-shaped to irregularly rounded cells with discrete, variably sized, clear cytoplasmic vacuoles, which were stained with oil red O in frozen sections of formalin-fixed tissue.
Natural Heterobilharzia americana infection in horses in Texas.
Veterinary pathology    January 24, 2012   Volume 49, Issue 3 552-556 doi: 10.1177/0300985811432346
Corapi WV, Snowden KF, Rodrigues A, Porter BF, Buote MA, Birch SM, Jackson ND, Eden KB, Whitley DB, Mansell J, Edwards JF, Hardy J, Chaffin MK.The schistosome Heterobilharzia americana infects dogs, raccoons, and other mammals in the southeastern United States. Migration of eggs into the liver results in parasitic granulomas with varying degrees of fibrosis and inflammation. Recently, hepatic parasitic granulomas in horses were shown to be caused by H. americana infection. In the present study, samples of liver from 11 of 12 horses with hepatic granulomas identified at necropsy (n = 11) or surgical biopsy (n = 1) were used for DNA extraction, polymerase chain reaction amplification and sequencing using primers specific for a portion ...
Clostridium perfringens type C and Clostridium difficile co-infection in foals.
Veterinary microbiology    December 1, 2011   Volume 156, Issue 3-4 395-402 doi: 10.1016/j.vetmic.2011.11.023
Uzal FA, Diab SS, Blanchard P, Moore J, Anthenill L, Shahriar F, Garcia JP, Songer JG.Clostridium perfringens type C is one of the most important agents of enteric disease in newborn foals. Clostridium difficile is now recognized as an important cause of enterocolitis in horses of all ages. While infections by C. perfringens type C or C. difficile are frequently seen, we are not aware of any report describing combined infection by these two microorganisms in foals. We present here five cases of foal enterocolitis associated with C. difficile and C. perfringens type C infection. Five foals between one and seven days of age were submitted for necropsy examination to the Californi...
Molecular detection of Coxiella burnetii and Neospora caninum in equine aborted foetuses and neonates.
Preventive veterinary medicine    November 29, 2011   Volume 104, Issue 1-2 179-183 doi: 10.1016/j.prevetmed.2011.11.001
Leon A, Richard E, Fortier C, Laugier C, Fortier G, Pronost S.Abortion, stillbirth and neonatal death are major causes of equine mortality and cause severe economic loss to the equine industry. The present study was based on a complete necropsy protocol associated with classical microbiological examinations and molecular biology on 407 cases of abortion, stillbirths and neonate death. Based on this retrospective survey, "less common" abortive infectious agents were characterised by molecular tools in nine independent cases of abortion or neonate mortality. Among others, Chlamydophila abortus (1 case), Coxiella burnetii (6 cases) and Neospora caninum (3 c...
Equine degenerative myeloencephalopathy in Lusitano horses.
Journal of veterinary internal medicine    November 19, 2011   Volume 25, Issue 6 1439-1446 doi: 10.1111/j.1939-1676.2011.00817.x
Finno CJ, Higgins RJ, Aleman M, Ofri R, Hollingsworth SR, Bannasch DL, Reilly CM, Madigan JE.Equine degenerative myeloencephalopathy (EDM) is a neurodegenerative disorder that has been previously associated with low vitamin E concentrations. Objective: To describe the clinical, electrophysiologic, and pathologic features of EDM in a group of related Lusitano horses. Methods: Fifteen Lusitano horses. Methods: Neurologic examinations were conducted, and serum vitamin E concentrations were measured. Three neurologically abnormal horses were further evaluated by ophthalmologic examination, electroretinography, electroencephalography, muscle and nerve biopsies, and post-mortem examination....
Insulin-dependent diabetes mellitus associated with presumed autoimmune polyendocrine syndrome in a mare.
The Canadian veterinary journal = La revue veterinaire canadienne    November 2, 2011   Volume 52, Issue 5 506-512 
Giri JK, Magdesian KG, Gaffney PM.A 5-year-old Thoroughbred-cross mare was diagnosed with insulin-dependent diabetes mellitus. Partial glycemic control and clinical improvement were achieved with daily insulin administration for 18 mo. The mare subsequently developed evidence of hypoadrenocorticism and died. Necropsy findings included lymphocytic infiltration of the pancreas, adrenal cortex, adrenal medulla, and thyroid glands, suggestive of an immune-mediated polyendocrinopathy. Une jument Thoroughbred croisée âgée de 5 ans a été diagnostiquée avec le diabète insulino-dépendant. Le contrôle glycémique partiel et lâ...
Heterobilharzia americana infection as a cause of hepatic parasitic granulomas in a horse.
Journal of the American Veterinary Medical Association    October 12, 2011   Volume 239, Issue 8 1117-1122 doi: 10.2460/javma.239.8.1117
Corapi WV, Birch SM, Carlson KL, Chaffin MK, Snowden KF.CASE DESCRIPTION-A 22-year-old American Paint Horse gelding from the Gulf Coast region of Texas was evaluated for regrowth of a perirectal squamous cell carcinoma that had been surgically removed 11 months previously. CLINICAL FINDINGS-A necrotic and ulcerated mass was present below the anus. The horse had paraphimosis and was having difficulty with urination. Histologic examination of the mass revealed that it was squamous cell carcinoma, and the horse was euthanized because of the unlikelihood that the mass could be adequately resected and its close proximity to the urethra. OUTCOME-At necro...
Characteristics of Thoroughbred and Quarter Horse racehorses that sustained a complete scapular fracture.
Equine veterinary journal    September 25, 2011   Volume 44, Issue 4 425-431 doi: 10.1111/j.2042-3306.2011.00481.x
Vallance SA, Case JT, Entwistle RC, Kinde H, Barr BC, Moore J, Anderson ML, Arthur RM, Stover SM.To determine if scapular fractures occur in racehorses with distinctive characteristics. Objective: To test the hypothesis that Thoroughbred (TB) and Quarter Horse (QH) racehorses with a scapular fracture have similar characteristics that are different from those of their respective racetrack populations. Methods: Necropsy findings, case details, last race information and career earnings for TB and QH racehorses that had a scapular fracture in California between 1990 and 2008 were retrospectively compared between breeds. Horse signalment, career earnings, career starts and race characteristics...
Comparison of transvaginal natural orifice transluminal endoscopic surgery (NOTES®) and laparoscopy for elective bilateral ovariectomy in standing mares.
Veterinary surgery : VS    September 23, 2011   Volume 40, Issue 8 998-1008 doi: 10.1111/j.1532-950X.2011.00877.x
Pader K, Freeman LJ, Constable PD, Wu CC, Snyder PW, Lescun TB.To compare surgical trauma, perioperative pain, surgical time, and complication rate in mares undergoing standing bilateral ovariectomy by natural orifice transluminal endoscopic surgery (NOTES) or laparoscopy. Methods: Experimental study. Methods: Healthy mares (n = 12). Methods: Ovariectomy was performed with a vessel-sealing device by transvaginal NOTES (n = 6) using a flexible endoscope and specialized instruments or by bilateral flank laparoscopy (n = 6). Preoperative and postoperative complete blood count (CBC), plasma fibrinogen concentration, serum amyloid A concentration, peritoneal n...
Evaluation of epidemiological, clinical, and pathological features of neuroaxonal dystrophy in Quarter Horses.
Journal of the American Veterinary Medical Association    September 16, 2011   Volume 239, Issue 6 823-833 doi: 10.2460/javma.239.6.823
Aleman M, Finno CJ, Higgins RJ, Puschner B, Gericota B, Gohil K, LeCouteur RA, Madigan JE.To describe epidemiological, clinical, and pathological features of neuroaxonal dystrophy in Quarter Horses (QHs) on a single farm. Methods: Prospective case series. Animals-148 horses. Methods: Neurologic, pathological, and toxicological evaluations were completed in selected neurologically affected horses over a 2-year period. Descriptive statistical analysis was performed. Results: 87 QHs and 1 QH-crossbred horse were affected. Most (50/88 [56.8%]) affected horses were 1 to 2 years old (median age, 2 years [range, 2 months to 34 years]). Neurologic deficits included obtundation (53/88 [60%]...
Strongylus vulgaris (Looss, 1900) in horses in Italy: is it still a problem?
Veterinary parasitology    September 16, 2011   Volume 184, Issue 2-4 161-167 doi: 10.1016/j.vetpar.2011.09.016
Pilo C, Altea A, Pirino S, Nicolussi P, Varcasia A, Genchi M, Scala A.A post-mortem survey was carried out on 46 Sardinian horses to evaluate the presence of Strongylus vulgaris and associated pathology. Horses were from local farms and had been treated with broad-spectrum anthelmintics at least 3 times a year. Examination of the cranial mesenteric arterial system (CMAS) showed parasite-induced lesions in all horses. S. vulgaris larvae were found in 39% of examined arteries, while their detection rate in coprocultures was 4%. Histology, carried out on 26 horses, showed mainly chronic and chronic-active lesions. Histometry showed a significant increase in thickne...
Acute selenium toxicosis in polo ponies. Desta B, Maldonado G, Reid H, Puschner B, Maxwell J, Agasan A, Humphreys L, Holt T.Just prior to an international polo event, 21 horses from one team exhibited clinical signs of central nervous system disturbance, hyperexcitability, sweating, ataxia, tachycardia, dyspnea, pyrexia, and rapid death. The suspected cause of this peracute onset of illness and death included intentional contamination of feed or iatrogenic administration of performance-enhancing drugs resulting in a severe adverse reaction. Six horses were submitted to the Bronson Animal Disease Diagnostic Laboratory for necropsy and toxicological examination. The clinical signs and sudden death, the similarity to ...
Disseminated lipid-rich peritoneal mesothelioma in a horse. Dobromylskyj MJ, Copas V, Durham A, Hughes TK, Patterson-Kane JC.A 9-year-old Haflinger mare presented to the Liphook Equine Hospital with a history of weight loss, azotemia, and repeated episodes of ascites over a period of 10 days. The horse was euthanized after exploratory laparotomy revealed large numbers of variably sized masses distributed throughout the peritoneal cavity. Macroscopically, some masses were papillary, while others were nodular. Histologically, the masses were comprised of large to giant, variably shaped, and occasionally multinucleated neoplastic cells with marked anisokaryosis and anisocytosis and a high mitotic rate. Small to moderat...
Standing ovariectomy in mares using a transvaginal natural orifice transluminal endoscopic surgery (NOTES®) approach.
Veterinary surgery : VS    September 7, 2011   Volume 40, Issue 8 987-997 doi: 10.1111/j.1532-950X.2011.00871.x
Pader K, Lescun TB, Freeman LJ.To develop and assess the feasibility of standing transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES®) ovariectomy in the mare. Methods: Descriptive study. Methods: Mares (n=10). Methods: The technique was developed in 6 mares and then evaluated in a short-term study in 4 mares. Abdominal access was developed using controlled access vaginal cannula placement under endoscopic guidance. With viewing provided by a flexible endoscope, hemostasis, and transection of ovarian pedicles was performed using a customized bipolar vessel-sealing device. The ovaries were retrieved and the ...
Computed tomographic findings in the pituitary gland and brain of horses with pituitary pars intermedia dysfunction.
Journal of veterinary internal medicine    August 30, 2011   Volume 25, Issue 5 1144-1151 doi: 10.1111/j.1939-1676.2011.00784.x
Pease AP, Schott HC, Howey EB, Patterson JS.Pituitary pars intermedia dysfunction (PPID) is the most common endocrinologic disorder of aged horses. Objective: Pituitary glands of PPID-affected horses are larger than those of aged horses without signs of PPID, and the size difference can be detected using computed tomography (CT) imaging. Methods: Eight horses with clinical signs of PPID and supportive endocrinologic test results and 3 aged control (PPID-negative) horses. Methods: Computed tomography examination of the brain and pituitary gland was performed twice in 10 of the 11 horses, approximately 6 months apart. Six PPID-affected ho...
Equine amnionitis and fetal loss: mare abortion following experimental exposure to Processionary caterpillars (Ochrogaster lunifer).
Equine veterinary journal    August 5, 2011   Volume 44, Issue 3 282-288 doi: 10.1111/j.2042-3306.2011.00424.x
Cawdell-Smith AJ, Todhunter KH, Anderson ST, Perkins NR, Bryden WL.In Australia, there have been recent reports of unusual abortions in mid- to late-gestation mares. These were clinically distinct from other recognised causes of pregnancy loss and the term 'equine amnionitis and fetal loss' (EAFL) was adopted to describe this syndrome. Initial investigations concluded that possible causal factors included the presence on affected stud farms of Processionary caterpillars (Ochrogaster lunifer). Objective: To determine if exposure of pregnant mares to Processionary caterpillars or their shed exoskeletons can induce EAFL. Methods: Processionary caterpillars and t...
Multiple small intestinal pseudodiverticula associated with lymphoma in three horses.
Equine veterinary journal. Supplement    August 4, 2011   Issue 39 128-132 doi: 10.1111/j.2042-3306.2011.00380.x
Mair TS, Pearson GR, Scase TJ.Three mature horses presented with progressive weight loss, inappetence, ventral abdominal oedema and lethargy. Two of the animals had intermittent signs of low grade abdominal pain. At presentation, all 3 had hypoalbuminaemia; 2 had hyperfibrinogenaemia and the other had neutrophilia. An oral glucose tolerance test was performed in 2 cases, both of which demonstrated impaired glucose absorption. One pony treated with corticosteroids failed to improve and developed peritonitis and was subjected to euthanasia after 2 weeks. One pony had small intestinal biopsies obtained via a standing flank la...
Equine rhabdomyolysis.
Veterinary pathology    August 1, 2011   Volume 48, Issue 6 E52-E58 doi: 10.1177/0300985811414034
Quist EM, Dougherty JJ, Chaffin MK, Porter BF.A 1.5-year-old Quarter Horse gelding with a history of chronic nasal discharge and leukocytosis presented with signs of increased lethargy and muscular pain. The horse quickly became recumbent and unable to rise and was euthanized due to a poor prognosis. At necropsy, severe bilateral guttural pouch empyema was observed, as well as numerous well-demarcated areas of pallor within the skeletal muscles of all major muscle groups. Polymerase chain reaction testing of the guttural pouch exudate confirmed an infection with Streptococcus equi subsp. equi, and an S. equi-associated immune-mediated rha...
Multiple small-intestine intussusceptions: a complication of purpura haemorrhagica in a horse.
Tijdschrift voor diergeneeskunde    June 28, 2011   Volume 136, Issue 6 422-426 
Dujardin CL.A Belgian draft horse stallion presented with classical signs of purpura haemorrhagica: oedema of the distal limbs, ventral abdomen and head, ecchymotic haemorrhage of mucous membranes, epistaxis, fever, lethargy, reluctance to move, and anorexia. Serum chemistry revealed a highly elevated gamma-globulin fraction. Streptococcal lymphadenitis (strangles) had been present on a neighbouring farm in the past few months. After an initial positive response to therapy with benzylpenicillin, flunixin and dexamethasone, the horse's condition deteriorated suddenly on day 4 of hospitalization, with signs...
1 9 10 11 12 13 42