Topic:Testosterone

Effect of age on androgens pattern in cyclic mares.
Research in veterinary science    April 24, 2024   Volume 173 105276 doi: 10.1016/j.rvsc.2024.105276
Satuu00e9 K, Fazio E, Damiu00e1 E, Barbiera G, Medica P, Cravana C.Androgens are produced in both sexes. In females produced by the adrenal gland and the ovaries they play a crucial role in regulating ovarian function, estrogen synthesis and follicular growth. Age leads to a reduction in androgen concentrations, although, at present, these mechanisms are not elucidated in mares. The objective of this study was to evaluate the concentrations of testosterone (T), androstenedione (A) and dehydroepiandrosterone (DHEA) in mares of different ages. Blood samples were drawn from seventy cyclic Spanish Purebred mares belonging to five age groups: 3-5 years, 6-9 year...
Early Castration in Horses Does Not Impact Osteoarticular Metabolism.
International journal of molecular sciences    November 26, 2023   Volume 24, Issue 23 16778 doi: 10.3390/ijms242316778
Rouge M, Legendre F, Elkhatib R, Delalande C, Cogniu00e9 J, Reigner F, Barriu00e8re P, Deleuze S, Hanoux V, Galu00e9ra P, Bourau00efma-Lelong H.The castration of stallions is traditionally performed after puberty, at around the age of 2 years old. No studies have focused on the effects of early castration on osteoarticular metabolism. Thus, we aimed to compare early castration (3 days after birth) with traditional castration (18 months of age) in horses. Testosterone and estradiol levels were monitored from birth to 33 months in both groups. We quantified the levels of biomarkers of cartilage and bone anabolism (CPII and N-MID) and catabolism (CTX-I and CTX-II), as well as of osteoarthritis (HA and COMP) and inflammation (IL-6 and PGE...
Evaluation of chemical castration using intra-testicular injection of zinc gluconate into the testis of the male donkey versus surgical castration: antimullerian hormone as an endpoint marker.
BMC veterinary research    September 2, 2023   Volume 19, Issue 1 140 doi: 10.1186/s12917-023-03694-1
Hamed MA, Amin YA, Mohamed RH, El-Adl M, Bazeed SM, Elnegiry AA, Shawki HH, Al-Lethie AA.Chemical castration of male animals is an alternative to surgical castration for inducing azoospermia, consequent sterility. Intra-testicular injection of zinc gluconate has been used for chemical castration in several animal species. However, its application to equine species, such as donkeys, has yet to be reported. This study aimed to evaluate the use of zinc gluconate for the chemical castration of male donkeys and to compare its effectiveness relative to routine surgical castration. For this purpose, investigations of serum testosterone and anti-Müllerian hormone levels, testicular ultra...
A hydrophobic deep eutectic solvent-based vortex-assisted liquid-liquid microextraction applied for doping control of aromatase inhibitors from equine urine.
Journal of pharmaceutical and biomedical analysis    July 14, 2023   Volume 234 115583 doi: 10.1016/j.jpba.2023.115583
Chen Q, Wang Z, Chen H.Aromatase inhibitors (AIs) can indirectly cause increased testosterone in animals, which leads to the improvement of the athletic ability of horses. For the protection of horses and the consideration of fair competition, AIs were listed as prohibited drugs by the Federation Equestre Internationale (FEI). There were several disadvantages using traditional pretreatment methods before analyzing these drugs from biological samples. A rapid and green pretreatment method has been developed by utilizing the hydrophobic deep eutectic solvent (DES)-based vortex-assisted liquid-liquid microextraction (D...
Hair Cortisol and Testosterone Concentrations in Relation to Maturity and Breeding Status of Male Feral Horses.
Animals : an open access journal from MDPI    June 27, 2023   Volume 13, Issue 13 doi: 10.3390/ani13132129
Medill SA, Janz DM, McLoughlin PD.Steroid-hormone concentrations from non-invasively obtained biomarkers, like hair, can provide a representation of circulating hormones diffused over relatively long time periods (e.g., weeks or months). The hormone cortisol is often associated with physiological or even psychological stress, while testosterone is strongly associated with male development and reproductive success. Increasingly, studies are using hormone levels derived from hair to make inferences among both domestic animals and wildlife. For horses, all previous hair hormone analysis has been done on companion or working anima...
Abnormal mare behaviour is rarely associated with changes in hormonal markers of granulosa cell tumours: A retrospective study.
Equine veterinary journal    June 21, 2023   doi: 10.1111/evj.13967
Huggins L, Norris J, Conley A, Dini P.Abnormal or undesired mare behaviours are often assumed to be associated with ovarian abnormalities. Objective: We aimed to determine the incidence of abnormal behaviours and their association with concentrations of one or more ovarian hormones associated with a granulosa cell tumour (GCT). Methods: Retrospective descriptive. Methods: A total of 2914 hormonal profile samples submitted with the words behave, behaviour, or behaving in the submission history were analysed. The association between reported abnormal behaviours and concentrations of testosterone, anti-Müllerian hormone (AMH), inhib...
Immunohistochemical markers for equine granulosa cell tumors: a pilot study.
Journal of equine science    June 12, 2023   Volume 34, Issue 2 37-46 doi: 10.1294/jes.34.37
Dolin A, Schweiger P, Waselau M, Egerbacher M, Walter I.Sex cord-stromal tumors (SCSTs), generally referred to as granulosa cell tumors (GCTs) or granulosa-theca cell tumors (GTCTs) in equids, show complex compositions and variable numbers of hormone-producing cells. These tumors can be difficult to diagnose, especially in early stages. Therefore, we tested a panel of antibodies for vimentin, smooth muscle actin, laminin, Ki-67, E-cadherin, calretinin, moesin, p-ezrin, AMH, and aromatase, markers used for tumor composition and classification, progression, and prognosis in human SCSTs, on an exemplary grapefruit-size equine GCT within the left ovary...
A review of current chemistry, pharmacology, and regulation of endogenous anabolic steroids testosterone, boldenone, and nandrolone in horses.
Journal of veterinary pharmacology and therapeutics    June 1, 2023   Volume 46, Issue 4 201-217 doi: 10.1111/jvp.13397
Dirikolu L, Lehner AF.Anabolic androgenic steroids are synthetic substances related to the male sex hormones (androgens). These agents promote the growth of skeletal muscle (anabolic effects) and the development of male sexual characteristics (androgenic effects). Anabolic steroids have been illegally used for many years as performance-enhancing drugs in human, equine, and canine sports and as growth promoters in livestock reared to provide meat for human consumption. The analytical challenge to developing effective means of control within these fields has been exacerbated by the reported endogenous nature of some ...
Development of a chronic focal equine arteritis virus infection of a male reproductive tract cell line.
Journal of virological methods    June 1, 2023   Volume 319 114756 doi: 10.1016/j.jviromet.2023.114756
Martu00edn-Faivre L, Gaudaire D, Laugier C, Bourau00efma-Lelong H, Zientara S, Hans A.Equine arteritis virus (EAV) is an Alphaarterivirus (family Arteriviridae, order Nidovirales) that frequently causes an influenza-like illness in adult horses, but can also cause the abortions in mares and death of newborn foals. Once primary infection has been established, EAV can persist in the reproductive tract of some stallions. However, the mechanisms enabling this persistence, which depends on testosterone, remain largely unknown. We aimed to establish an in vitro model of non-cytopathic EAV infection to study viral persistence. In this work, we infected several cell lines originating f...
Detection of boldenone in the urine of female horses-ex vivo formation versus administration.
Drug testing and analysis    June 1, 2023   doi: 10.1002/dta.3521
Viljanto M, Kaabia Z, Taylor P, Hincks P, Muir T, Habershon-Butcher J, Bailly-Chouriberry L, Scarth J.Boldenone is an anabolic-androgenic steroid (AAS) that is prohibited in equine sports. However, in certain situations, it is endogenous, potentially formed by the microbes in urine. An approach to the differentiation based on the detection of the biomarkers Δ1-progesterone, 20(S)-hydroxy-Δ1-progesterone and 20(S)-hydroxyprogesterone was assessed, and their concentrations were monitored in the urine of untreated female horses (n = 291) alongside boldenone, boldienone, testosterone and androstenedione. Using an ultra-sensitive analytical method, boldenone (256 ± 236 pg/mL, n = 2...
Detection of gonadotropin-releasing hormone and its analogues in equine and canine urine by high-resolution data-independent acquisition.
Drug testing and analysis    May 3, 2023   Volume 15, Issue 8 896-908 doi: 10.1002/dta.3486
Timms M, Botteon A, Manos C, Griffin J, Levina V, Steel R.Gonadotropin-releasing hormone (GnRH) and its synthetic analogues are considered banned substances by the racing industry. GnRH is used as a pharmaceutical to regulate the female oestrous cycle, but the hormone is also thought to increase the production of testosterone in male animals. Using liquid chromatography in conjunction with high-resolution mass spectrometry (LC-HRMS) and data-independent acquisition (DIA), a method is presented for the detection of intact and truncated peptides of GnRH and its analogues down to the low picogram level in equine urine. The study of the catabolism of GnR...
Exercise-related changes in the anabolic index (testosterone to cortisol ratio) and serum amyloid A concentration in endurance and racehorses at different fitness levels.
Frontiers in veterinary science    April 17, 2023   Volume 10 1148990 doi: 10.3389/fvets.2023.1148990
Grzu0119dzicka J, Du0105browska I, Malin K, Witkowska-Piu0142aszewicz O.Increased training loads in both human and equine athletes are generally implemented to improve their physical performance. These loads are tolerated only within appropriate training periodization with regard to recovery time. Otherwise, training overload causes failure in the systemic adaptation, which at first leads to overreaching, and progressively to overtraining syndrome (OTS). Exercise endocrinology, and anabolic/catabolic balance as an indicator of athlete performance status and OTS has continued to attract attention. In human medicine, changes in testosterone and cortisol levels, as w...
Performance assessment of an equine metabolomics model for screening a range of anabolic agents.
Metabolomics : Official journal of the Metabolomic Society    April 7, 2023   Volume 19, Issue 4 38 doi: 10.1007/s11306-023-01985-0
Cloteau C, Dervilly G, Loup B, Delcourt V, Kaabia Z, Bagilet F, Groseille G, Dauriac K, Fisher S, Popot MA, Garcia P, Le Bizec B, Bailly-Chouriberry L.Despite their ban, Anabolic Androgenic Steroids (AAS) are considered as the most important threat for equine doping purposes. In the context of controlling such practices in horse racing, metabolomics has emerged as a promising alternative strategy to study the effect of a substance on metabolism and to discover new relevant biomarkers of effect. Based on the monitoring of 4 metabolomics derived candidate biomarkers in urine, a prediction model to screen for testosterone esters abuse was previously developed. The present work focuses on assessing the robustness of the associated method and def...
Dual use of breeding stallions is possible without affecting the sperm quality.
Reproduction in domestic animals = Zuchthygiene    March 16, 2023   Volume 58, Issue 6 691-698 doi: 10.1111/rda.14337
Hensel B, Jakop U, Schmicke M, Schru00f6ter F, Jung M, Schulze M.Artificial insemination (AI) is commonly used in the equine industry to enhance the genetic value in breeding programs and to effectively utilize ejaculates. Many stallions are used as breeding stallions as well as in high-level sports competitions to improve their market value. The goal of the present study was to investigate whether this dual use of stallions influences the animals´ stress levels and/or the quality of their ejaculates. For this purpose, 18 stallions were grouped into two categories: breeding stallions with (BSC = breeding stallion competition), and breeding stallions with...
Seasonality does not influence cortisol or testosterone production, or seminal quality of stallions located at low latitudes.
Animal reproduction science    February 23, 2023   Volume 250 107202 doi: 10.1016/j.anireprosci.2023.107202
Freitas ML, Viana JHM, Dode MAN, Maggiotto SR, Pivato I, Braga TRC, Lim AIPG, de Oliveira RA.The effects of seasonality on the reproduction of stallions vary based on the latitude. Although previous studies have shown the influence of seasonality in raw semen quality in south-eastern Brazil, data regarding the influence of seasonality in cooled and frozen stored semen in Brazil is limited. Therefore, in this study, we have analysed if seasonality influences the hormone production (i.e., cortisol and testosterone), spermatogenesis, and quality of fresh, cooled, and frozen semen of stallions in central Brazil, and established the season most suitable for semen cryopreservation in a lati...
Investigation of in vitro generated metabolites of GLPG0492 using equine liver microsomes for doping control.
Drug testing and analysis    February 19, 2023   Volume 15, Issue 6 605-628 doi: 10.1002/dta.3453
Karatt TK, Sathiq MA, Laya S, Philip M, Karakka Kal AK, Subhahar MB.An effective alternative to testosterone therapy is selective androgen receptor modulators, a class of compounds that has a tissue-specific effect on muscle and bone. These drugs, which enhance performance, pose a severe abuse risk in competitive sports. GLPG0492 is one of the selective androgen receptor modulators discovered in recent decades. This compound has a unique tissue-specific action for muscle and bone against steroid receptors and acts as a partial agonist for androgen receptors. This study examined GLPG0492 and its metabolites in vitro using equine liver microsomes. Liquid chromat...
Monorchidism in a Phenotypic Mare With a 64,XY, SRY-Positive Karyotype.
Journal of equine veterinary science    February 1, 2023   Volume 126 104232 doi: 10.1016/j.jevs.2023.104232
Middlebrooks B, McCue P, Nelson B, May E, Divine C, Barton C, Conley A.Disorders of sexual development (DSD) are associated with atypical chromosomal, gonadal, or phenotypic sex. It is likely that the number of cases of DSD are underestimated in the equine population. Monorchidism in the horse is very rare. This case report describes the clinical assessment of a phenotypic mare with stallion-like behavior which led to the diagnosis of a DSD. A 4-year-old Quarter Horse mare presented in good body condition, with normal external genitalia for a mare, and normal mammary glands with two bilaterally symmetric teats. No uterus, cervix, or gonads were detected on transr...
Re-stimulation of testicular function in GnRH-vaccinated stallions by daily GnRH agonist treatment.
Theriogenology    September 24, 2022   Volume 194 27-34 doi: 10.1016/j.theriogenology.2022.09.011
Gautier C, Aurich J, Kaps M, Okada CTC, Wagner LH, Melchert M, Aurich C.In stallions temporarily not intended for breeding, reversible suppression of testicular function by vaccination against GnRH can be of interest. In the present study, effects of GnRH agonist treatment on the resumption of testicular function after GnRH vaccination were investigated. Testis size, testosterone release, semen characteristics and behavior were evaluated. We hypothesized that GnRH agonist treatment would restore testicular function. Shetland stallions were assigned to an experimental and a control group (n = 6 each). Experimental stallions were GnRH-immunized twice, four weeks a...
Effects of an anti-gonadoliberin releasing hormone vaccine on testicular, epididymal and spermatogenic development in the horse.
Reproduction in domestic animals = Zuchthygiene    May 12, 2022   Volume 57, Issue 8 919-927 doi: 10.1111/rda.14141
Botha AE, Schulman ML, Birrell J, du Plessis L, Laver PN, Soley J, Colenbrander B, Bertschinger HJ.The effects of the GnRH vaccine Improvac on testicular and epididymal morphometrics, histology and spermatogenesis were measured in 19 young (15-20 months) colts randomly assigned to one control (saline, castration at 57 days, n = 6) or either of two GnRH vaccine-treatment groups, T-57 (castration at 57 days, n = 7) or T-100 (castration at 100 days, n = 6), respectively. All were immunized on Day 0 with a single booster on Day 28. Excised testes and epididymides were weighed and processed for histology to measure tubule, epithelial and muscle dimensions, the ratio of interstitial tis...
Evaluation of testicular echotexture with Ecotext as a diagnostic method of testicular dysfunction in stallions.
Theriogenology    March 16, 2022   Volume 185 50-60 doi: 10.1016/j.theriogenology.2022.03.004
Da Silva-u00c1lvarez E, Gaitskell-Phillips G, Ortiz-Rodru00edguez JM, Serres C, Garcu00eda-Rodru00edguez B, Gutiu00e9rrez-Cepeda L....This study aimed to assess if Ecotext, a new software for evaluation of testicular echotexture, is a good method for diagnosis of stallions with testicular dysfunction (TD). Relationships between Ecotext parameters and sperm motility and production, testicular volume, and testicular blood flow were also studied. Ecotext provides a total of six echotexture parameters: Ecotext 1 (black pixels), 2 (white pixels) and 3 (grey pixels), and another 3 parameters related to hypoechogenic areas: Ecotext tubular density (ETD), Ecotext tubular diameter (ETd), and Ecotext tubular area (ETA). Stallions (n ...
Differentiation of boldenone administration from ex vivo transformation in the urine of castrated male horses.
Drug testing and analysis    February 28, 2022   Volume 14, Issue 5 887-901 doi: 10.1002/dta.3240
Viljanto M, Kaabia Z, Taylor P, Muir T, Habershon-Butcher J, Bailly-Chouriberry L, Scarth J.Boldenone is an anabolic-androgenic steroid that is prohibited in equine sports. However, in certain situations, it is endogenous or is believed to be formed by microbes in urine, and therefore, an approach for the differentiation is required. Following the identification of Δ1-progesterone and 20(S)-hydroxy-Δ1-progesterone as potential biomarkers of microbial activity, the presence of six steroids was investigated in the postrace urine of castrated male horses (geldings, n = 158). In line with endogenous findings from several other species when ultrasensitive methods are employed, bolde...
Profiling Urinary Sulfate Metabolites With Mass Spectrometry.
Frontiers in molecular biosciences    February 23, 2022   Volume 9 829511 doi: 10.3389/fmolb.2022.829511
Fitzgerald CCJ, Hedman R, Uduwela DR, Paszerbovics B, Carroll AJ, Neeman T, Cawley A, Brooker L, McLeod MD.The study of urinary phase II sulfate metabolites is central to understanding the role and fate of endogenous and exogenous compounds in biological systems. This study describes a new workflow for the untargeted metabolic profiling of sulfated metabolites in a urine matrix. Analysis was performed using ultra-high-performance liquid chromatography-high resolution tandem mass spectrometry (UHPLC-HRMS/MS) with data dependent acquisition (DDA) coupled to an automated script-based data processing pipeline and differential metabolite level analysis. Sulfates were identified through -means clustering...
Estrogens Regulate Placental Angiogenesis in Horses.
International journal of molecular sciences    November 9, 2021   Volume 22, Issue 22 12116 doi: 10.3390/ijms222212116
Haneda S, Dini P, Esteller-Vico A, Scoggin KE, Squires EL, Troedsson MH, Daels P, Nambo Y, Ball BA.A sufficient vascular network within the feto-maternal interface is necessary for placental function. Several pregnancy abnormalities have been associated with abnormal vascular formations in the placenta. We hypothesized that growth and expansion of the placental vascular network in the equine () placenta is regulated by estrogens (estrogen family hormones), a hormone with a high circulating concentration during equine gestation. Administration of letrozole, a potent and specific inhibitor of aromatase, during the first trimester (D30 to D118), decreased circulatory estrone sulfate concentrat...
Systemic and Intrafollicular Androgen Concentrations in Cycling Mares.
Journal of equine veterinary science    September 11, 2021   Volume 106 103759 doi: 10.1016/j.jevs.2021.103759
Satuu00e9 K, Fazio E, Cravana C, Medica P.The evidence that androgens regulate the folliculogenesis supports the hypothesis that intrafollicular testosterone (T), androstenedione (A) and dehydroepiandrosterone (DHEA) could be modified along follicular growth. The objective of this study was to evaluate the changes and related relationships between systemic and intrafollicular T, A and DHEA in post-deviation and impending ovulation follicles. Sixty ovaries were taken after the slaughter of 30 clinically healthy mares. In according to the sizes, the follicles were classified in 3 different categories, as small (20-30 mm), medium (31-40 ...
Hair Cortisol, Testosterone, Dehydroepiandrosterone Sulfate and Their Ratios in Stallions as a Retrospective Measure of Hypothalamic-Pituitary-Adrenal and Hypothalamic-Pituitary-Gonadal Axes Activity: Exploring the Influence of Seasonality.
Animals : an open access journal from MDPI    July 25, 2021   Volume 11, Issue 8 2202 doi: 10.3390/ani11082202
Olvera-Maneu S, Carbajal A, Gardela J, Lopez-Bejar M.The monitoring of stress physiology includes studying a wide range of endocrinological mechanisms, which can be assessed using multiple tissue samples. This study aimed to evaluate the seasonal variations of hair C, T and DHEA-S in horses for a whole year, as well as to assess the variations between seasons of C/DHEA-S and T/C ratios as a retrospective measure of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axis activity. Ten pure-breed Menorca stallions were included in the study. The hair samples were collected approximately every two months following the shave-resha...
Evaluation of the subcapsular technique for primary closure castration in donkeys (Equus asinus).
Scientific reports    July 7, 2021   Volume 11, Issue 1 14080 doi: 10.1038/s41598-021-93585-y
Ibrahim A, Mahmoud UT, Ali MM, Ragab SMM.This study described the subcapsular technique for primary closure castration in donkeys with special regard to its efficiency and welfare impacts. The study was conducted on twelve adult male donkeys, allocated randomly into two groups; subcapsular castration (SC) and open castration (OC) groups, whether the donkeys were subjected to surgical castration either by subcapsular or open castration techniques, respectively. Testosterone, cortisol, lactate, glucose, total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), triglyceride (TG), and nitric oxide (NO) were measured before an...
Quantification of 17 Endogenous and Exogenous Steroidal Hormones in Equine and Bovine Blood for Doping Control with UHPLC-MS/MS.
Pharmaceuticals (Basel, Switzerland)    April 21, 2021   Volume 14, Issue 5 393 doi: 10.3390/ph14050393
Caprioli G, Genangeli M, Mustafa AM, Petrelli R, Ricciutelli M, Sagratini G, Sartori S, Laus F, Vittori S, Cortese M.A simple and fast analytical method able to simultaneously identify and quantify 17 endogenous and exogenous steroidal hormones was developed in bovine and equine blood using UHPLC-MS/MS. A total amount of 500 µL of sample was deproteinized with 500 µL of a mixture of methanol and zinc sulfate and evaporated. The mixture was reconstituted with 50 µL of a solution of 25% methanol and injected in the UHPLC-MS/MS triple quadrupole. The correlation coefficients of the calibration curves of the analyzed compounds were in the range of 0.9932-0.9999, and the limits of detection and quantification ...
Vaccination against GnRH as a prelude to surgical castration of horses.
Equine veterinary journal    January 20, 2021   Volume 53, Issue 6 1141-1149 doi: 10.1111/evj.13411
Birrell JR, Schulman ML, Botha AE, Ganswindt A, Fosgate GT, Bertschinger HJ.Surgical castration is one of the most frequently performed surgeries in horses and is associated with various post-surgical complications ranging in severity. Objective: We investigated the effects of administering an anti-GnRH vaccine to colts for reduction of testis size on the incidence of complications associated with their subsequent surgical castration. Methods: Randomised open controlled trial. Methods: Nineteen colts were randomly assigned to one of the three groups. Treatment Groups V1-57 and V2-100 received two treatments of Improvac (Zoetis, South Africa) before their castration in...
Hormone Concentrations and Semen Parameters in Criollo Breed Stallions Under Training.
Journal of equine veterinary science    January 13, 2021   Volume 99 103386 doi: 10.1016/j.jevs.2021.103386
Rossetto L, Farcey MF, Bilbao MG, Bartolomu00e9 JA, Gallelli MF, Miragaya MH.The stress associated with training may reduce reproductive efficiency in Criollo stallions. The objective of this study was to compare semen quality and hormone concentrations in Criollo stallions under training or under regular field conditions. Criollo breed stallions (n = 18) were evaluated during the spring. The exercise group (n = 9) performed 1 hour of exercise per day and participated in competitions during the experimental period. The control group (n = 9) neither performed exercise nor participated in competitions. Serum and semen samples were obtained every 15 days (two separat...
Dynamics of androgens in healthy and hospitalized newborn foals.
Journal of veterinary internal medicine    December 5, 2020   Volume 35, Issue 1 538-549 doi: 10.1111/jvim.15974
Swink JM, Rings LM, Snyder HA, McAuley RC, Burns TA, Dembek KA, Gilsenan WF, Browne N, Toribio RE.Information on steroids derived from the adrenal glands, gonads, or fetoplacental unit is minimal in newborn foals. Objective: To measure androgen concentrations in serum and determine their association with disease severity and outcome in hospitalized foals. Methods: Hospitalized (n = 145) and healthy (n = 80) foals. Methods: Prospective, multicenter, cross-sectional study. Foals of ≤3 days of age from 3 hospitals and horse farms were classified as healthy and hospitalized (septic, sick nonseptic, neonatal maladjustment syndrome [NMS]) based on physical exam, medical history, and laborato...
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