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Behavioral Signature of Equine Gastric Discomfort? Preliminary Retrospective Clinical Observations.
Animals : an open access journal from MDPI    January 3, 2025   Volume 15, Issue 1 doi: 10.3390/ani15010088
Torcivia C, McDonnell SM.Gastric ulcer disease and other potentially painful gastric conditions are among the most common afflictions adversely affecting the welfare of domestic equids. A large percentage of affected animals may not display the classic signs of gastric disease, such as unexplained weight loss, poor hair coat, and inappetence until the disease becomes severe. As a clinical service within our equine referral hospital, we routinely evaluate 24-h video recorded samples of horses to assist clinicians in identifying subtle discomfort and potential sources or to scan for infrequent neurologic or cardiac-rela...
Plasma Cardiac Troponin-I Concentration in Normal Horses and in Horses with Cardiac Abnormalities.
Animals : an open access journal from MDPI    January 3, 2025   Volume 15, Issue 1 doi: 10.3390/ani15010092
Foreman JH, Tennent-Brown BS, Oyama MA, Sisson DD.Cardiac troponin-I (cTnI) is a highly sensitive and specific marker of myocardial injury detectable in plasma by immunoassay techniques. Inclusion criteria over a 3-year period required a diagnosis of cardiac disease accompanied by electrocardiographic (ECG) and cardiac ultrasound examinations (n = 23) in adult horses (≥2 years of age). A second group of normal adult ponies (n = 12) was studied as a reference group. Heparinized jugular venous blood samples were collected and centrifuged within 30 min, and the plasma was separated and frozen at -70 °C for subsequent batched cTnI analysis. Th...
Equine piroplasmosis in different geographical areas in France: Prevalence heterogeneity of asymptomatic carriers and low genetic diversity of Theileria equi and Babesia caballi.
Ticks and tick-borne diseases    January 3, 2025   Volume 16, Issue 1 102434 doi: 10.1016/j.ttbdis.2024.102434
Jouglin M, Bonsergent C, de la Cotte N, Mège M, Bizon C, Couroucé A, Lallemand ÉA, Leblond A, Lemonnier LC, Leroux A, Marano I, Muzard A....Equine piroplasmosis is a worldwide tick-borne disease caused by the parasites Theileria equi sensu lato and Babesia caballi, with significant economic and sanitary consequences. These two parasites are genetically variable, with a potential impact on diagnostic accuracy. Our study aimed to evaluate the frequency of asymptomatic carriers of these parasites in France and describe the circulating genotypes. We developed a species-specific nested PCR protocol targeting the 18S small sub-unit (SSU) rRNA gene and used it on blood samples collected from 566 asymptomatic horses across four National V...
Ovarian steroids modulate mRNA expression of ECM associated genes and collagen deposition induced by TGF β1 in equine endometrium in vitro.
Scientific reports    January 2, 2025   Volume 15, Issue 1 538 doi: 10.1038/s41598-024-84250-1
Ana A, Agnieszka S, Marta CP, Pawel K, Dariusz S, Graça FD, Szóstek-Mioduchowska A.Equine endometrosis is a major cause of infertility in mares and is characterized by degenerative, functional and fibrotic changes in the endometrium with increased collagen (COL) deposition. Transforming growth factor (TGF)-β1 is one of the major pro-fibrotic factors involved in the excessive deposition of extracellular matrix (ECM) components in the equine endometrium. It has been demonstrated that ovarian steroids, specifically 17β-estradiol (E2) and progesterone (P4), not only regulate the cyclicity of the estrous cycle, but also have been implicated as anti- or pro-fibrotic factors. Thi...
Torsemide can be used for long-term management of congestive heart failure in equids: a description of 12 cases (2019-2024).
Journal of the American Veterinary Medical Association    January 2, 2025   1-5 doi: 10.2460/javma.24.08.0499
Shroff K, Stefanovski D, Reef VB, Kraus MS, Solis CN.Information about congestive heart failure (CHF) treatment in the horse is limited. Torsemide, an oral loop diuretic, is increasingly used in humans, dogs, and cats with CHF. Torsemide is well absorbed and induces diuresis in healthy horses, and its use in a horse with CHF has been reported. This retrospective descriptive study aimed to describe the use of torsemide in equids with CHF. Methods: 12 equids (10 horses, 1 miniature donkey, and 1 mule). Methods: Horses presented to a referral practice with clinical signs of congestive heart failure. Diagnosis was confirmed with echocardiography. Tr...
Review of biological variation and its applications in interpretation of equine clinical pathology results.
Equine veterinary journal    January 2, 2025   doi: 10.1111/evj.14454
Fernandes T, Robin M, Freeman KP.Biological variation in laboratory results refers to physiological fluctuations that occur around a homeostatic setpoint (HSP) for various laboratory measurands. Assessment of biological variation includes determining individual variation (CV), group variation (CV), and analytical variation (CV). Reference change value (RCV) is an objective tool for an evidence-based approach to interpret data by assessing the significance of consecutive results in an individual for the diagnosis, prognosis, and monitoring of disease. The individualised reference intervals (iRI) are derived from the determinat...
Ethylene glycol toxicosis in 39 sport horses following ingestion of contaminated water: A case report.
Journal of equine veterinary science    January 2, 2025   Volume 145 105343 doi: 10.1016/j.jevs.2025.105343
Daradics Z, Bungărdean D, Lupșan AF, Popescu M, Bulmez O, Ciulu-Angelescu V, Chelaru VF, Morar I, Mircean M, Cătoi C, Tripon MA, Crecan CM.Ethylene glycol toxicosis is a common occurrence in dogs and cats but has been reported in other species as well. Up to date, only one case of ethylene glycol toxicosis has been described in horses, and specific guidelines for treating ethylene glycol intoxication in this species are not available. Here we describe the case of 39 sport horses that ingested water contaminated with ethylene glycol. The main clinical sign was apathy, but more severely affected individuals also developed abdominal pain and laminitis. Treatment was initiated around 24 h after the exposure, using ethanol as an antid...
Equine endometrial bacteria inhibition by metabolite and extracellular vesicles of Lactobacillus acidophilus and lactiplantibacillus plantarum.
Veterinary research communications    January 2, 2025   Volume 49, Issue 1 61 doi: 10.1007/s11259-024-10626-3
Bernabe MCM, Fonseca BB, Silva MVC, Pedrosa IE, Silva MB, Sommerfeld S, de Sousa ALP, de Leva Resende BC, Sousa ACP, Dos Santos Freitas A....Endometritis is one of the main reproductive disorders in mares and due to the increasing prevalence of antibiotic resistance, the use of probiotics in the prevention and treatment of endometritis in mares has gained interest, given their potential to restore and maintain a healthy uterine microbiota. Therefore, the aim of this study was to evaluate the antimicrobial properties of total metabolites of Lactobacillus acidophilus (LA) and Lactiplantibacillus plantarum (LP) against common equine endometrial pathogenic bacteria in vitro (Acinetobacter baumannii, Escherichia coli (1), Escherichia co...
Effects of anesthetic protocol, procedure, and recovery stall and interval on the quality of recovery in repeatedly anesthetized horses. Henderson ARP, Valverde A, Koenig J, Sears W.The objective of this prospective study was to investigate whether repeated consecutive general anesthesia in horses undergoing 2 different anesthetic protocols could lead to improved recovery scores. Six healthy female Standardbred horses (453 ± 57 kg; 6.5 ± 4.2 y old) underwent 4 anesthetic protocols over 12 to 13 wk. Procedures 1 and 4 were arthroscopic surgeries [induction: xylazine, diazepam, and ketamine; and maintenance: Fe'Isoflurane (1.1%), lidocaine (2 mg/kg body weight [BW], 50 to 100 μg/min per kg BW), dexmedetomidine (2.5 μg/h per kg BW)]. Procedures 2 and 3 were preparation f...
Comparison of nasal swabs and handmade foam cubes for detecting equine herpesvirus 5 (EHV-5) by quantitative polymerase chain reaction (qPCR). Charbonnel A, Lavoie JP, Juette T, St-Sauveur VG, Denis S, Gagnon CA, Leclère M.The control of equine respiratory infections is a biosecurity challenge. Respiratory viruses are often rapidly detected using quantitative polymerase chain reaction (qPCR) on nasal swabs. In the past, some laboratories developed handmade techniques to increase the amount of nasal secretions collected, without comparing them with nasal swabs when qPCR replaced the use of viral culture. The objectives of this study were to compare nasal swabs and handmade foam cubes for i) the detection of a common equine herpesvirus (EHV-5) by qPCR, and ii) their tolerability. Forty-five polyester swabs and foa...
Soft palate angle and basihyoid depth increase with tongue size and with body condition score in horses.
Equine veterinary journal    January 2, 2025   doi: 10.1111/evj.14445
Talbot AM, Shanks-Boon H, Baldwin CM, Barnes H, Maddox TW.Obesity has been associated with human obstructive sleep apnoea and canine brachycephalic obstructive airway syndrome. The effect of body condition score (BCS) on structures of the oropharynx, nasopharynx and upper airway of the horse has not been investigated. Objective: To investigate the effect of BCS on tongue measurements, soft palate angle and basihyoid depth in horses. Methods: Retrospective, analytical, cross-sectional. Methods: Computed tomographic (CT) images of the head of 58 horses were assessed. DICOM viewing software was used to measure head length, basihyoid-skin depth, soft pal...
Molecular basis for shifted receptor recognition by an encephalitic arbovirus.
bioRxiv : the preprint server for biology    January 2, 2025   2025.01.01.631009 doi: 10.1101/2025.01.01.631009
Fan X, Li W, Oros J, Plung JS, Plante JA, Basu H, Nagappan-Chettiar S, Boeckers JM, Tjang LV, Mann CJ, Brusic V, Buck TK, Varnum H, Yang P....After decades of inactivity throughout the Americas, western equine encephalitis virus (WEEV) recently re-emerged in South America, causing a large-scale outbreak in humans and horses. WEEV binds protocadherin 10 (PCDH10) as a receptor; however, nonpathogenic strains no longer bind human or equine PCDH10 but retain the ability to bind avian receptors. Highly virulent WEEV strains can also bind the very low-density lipoprotein receptor (VLDLR) and apolipoprotein E receptor 2 (ApoER2) as alternative receptors. Here, by determining cryo-electron microscopy structures of WEEV strains isolated from...
Equestrian Sports Safety: An Update on Safety Equipment and Event Medical Coverage.
Current sports medicine reports    January 1, 2025   Volume 24, Issue 1 11-17 doi: 10.1249/JSR.0000000000001222
Gould S, Roy IR, Gabriel FD, Lowe R, Lin CY.Equestrian sports are associated with high rates of major injury compared to collision and powered two-wheel sports. Advancements in rider and horse safety equipment and the implementation of comprehensive emergency action planning standards may help mitigate injuries, particularly in regard to the Olympic disciplines of dressage, show jumping, and three-day eventing covered in this review. Personal safety equipment to consider includes helmets, safety and air vests, and horse tack including safety stirrups, acoustic dampeners, and breakaway reins. Equestrian event medical coverage requires em...
Post competition recovery of hydroelectrolytic and acid-base variables under distinct comfort indexes in equines participating in 90 km Federate RAID.
Open veterinary journal    December 31, 2024   Volume 14, Issue 12 3203-3212 doi: 10.5455/OVJ.2024.v14.i12.5
Marichal G, Suárez G, Meikle A, Muriel M.The recovery of acid-base and hydro electrolytic balance at medical discharge after Raid races and its association with comfort index (CI) is unknown. Unassigned: To determine hydroelectrolytic and acid-base variations before and at the time of clinical discharge in horses that completed 90 km Raid competitions. Unassigned: Hematocrit, total protein, sodium, potassium, chloride, calcium, and serum pH were determined in samples before and after the race and after hydration in 276 horses and were analyzed using a mixed procedure, including the time of the race, the CI and its interaction. Unassi...
Diagnosis and genomic characterization of the largest western equine encephalitis virus outbreak in Uruguay during 2023-2024.
Npj viruses    December 31, 2024   Volume 2, Issue 1 70 doi: 10.1038/s44298-024-00078-6
The Western equine encephalitis virus is transmitted between mosquitoes and wild birds. Mosquitoes spread the virus to horses and human populations, causing severe encephalitis and death. The most recent large outbreak occurred in South America from November 2023 to April 2024. We identified and genetically characterized Uruguayan strains during this outbreak to understand their evolutionary trends and rapid expansion. We obtained genomes from 15 strains using a novel multiplex PCR assay combined with next-generation Illumina sequencing. The phylogenetic analysis revealed that viruses from Uru...
Factors influencing oocyte recovery during ultrasound-guided follicle aspiration in mares: A postmortem study.
Theriogenology    December 31, 2024   Volume 235 39-45 doi: 10.1016/j.theriogenology.2024.12.032
Márquez-Moya A, Sala-Ayala L, Carreras-Vico N, Martínez-Boví R, Cuervo-Arango J.The objectives of this study were to investigate the influence of different OPU variables (vacuum and injection pressures during follicle aspiration and flushing, needle twisting to scrape follicles, number of follicle flushes and type of flushing media) on oocyte recovery rate (ORR) and morphology. Overall, 120 postmortem excised ovaries were processed in 62 replicates (1.9 ± 0.7 ovaries per replicate), with a total of 1336 follicles punctured and aspirated (11.1 ± 6.2 follicles per ovary) by ultrasound-guided follicle aspiration resembling the OPU procedure from live mares. The aspirat...
Pharmacodynamics and pharmacokinetics of rocuronium in sevoflurane-anesthetized Thoroughbred horses.
Veterinary anaesthesia and analgesia    December 30, 2024   S1467-2987(24)00418-5 doi: 10.1016/j.vaa.2024.12.006
Kodaira K, Kakizaki M, Nagata SI, Ode H, Okano A, Tamura N, Mizobe F, Matsuda Y, Kurimoto S, Aida H.To investigate the pharmacodynamics and pharmacokinetics of rocuronium administered by bolus injection to sevoflurane-anesthetized horses. Methods: Prospective, experimental, crossover study. Methods: Five healthy adult Thoroughbred horses (body mass 368-470 kg, three females and two males). Methods: Each horse was anesthetized twice with sevoflurane and assigned to be administered rocuronium bromide intravenously: 0.2 mg kg (R02) or 0.4 mg kg (R04). There was a minimum 2 week washout period between experiments. During anesthesia, the peroneal nerve was stimulated (train-of-four) and neuromusc...
Marked blastomere herniation is the only post-thaw morphological characteristic associated with a reduced pregnancy rate for in vitro produced equine blastocysts.
Theriogenology    December 30, 2024   Volume 235 1-8 doi: 10.1016/j.theriogenology.2024.12.028
Arnold LC, Stout TAE, Beitsma MM, Deelen CC, Rizzo M, Leemans B, Galli C, Colleoni S, Lazzari G, Barandalla M, Claes ANJ.It is not known whether the likelihood of pregnancy after transfer of cryopreserved equine in vitro produced (IVP) blastocysts is related to post-thaw morphological characteristics, or could be impacted by other factors such as embryo biopsy prior to cryopreservation. This study examined associations between post-thaw morphological appearance of equine IVP embryos, and biopsy prior to slow-freezing, on the likelihood of pregnancy. Biopsy of IVP blastocysts was performed by harvesting cells herniated through the intra-cytoplasmic sperm injection (ICSI)-derived hole in the zona pellucida (ZP). M...
Protocol to implement and evaluate a culturally secure, strength-based, equine-assisted learning program, “Yawardani Jan-ga” (horses helping), to support the social and emotional wellbeing of Australian aboriginal children and young people.
PloS one    December 30, 2024   Volume 19, Issue 12 e0312389 doi: 10.1371/journal.pone.0312389
Coffin J, Vaz S, Kickett-Tucker C, Milroy H, Olsson C, Kirby M, Nelson L, McPhee R, Cross D.Australian Aboriginal people experience stressors from inequalities across crucial social determinants, including deep and entrenched disadvantage and exclusion. The impact of unaddressed historical issues is pervasive and intergenerational. The disproportionate rates of Aboriginal youth suicide, juvenile detention and imprisonment highlight the inadequacy of existing social and emotional wellbeing programs and services for Aboriginal children and young people. There is increasing recognition in Australia that aligning social and emotional wellbeing interventions with Western values and concep...
Application of thermography in the assessment of physical effort on body surface temperature distribution in racehorses.
Polish journal of veterinary sciences    December 30, 2024   Volume 27, Issue 2 221-227 doi: 10.24425/pjvs.2024.149352
Soroko-Dubrovina M, Åšniegucka K, Dobrowolski M, Dudek KD.The aim of this study was to evaluate the efficacy of thermography in assessing the impact of regular physical effort on changes in the body surface temperature of the upper body parts of young racehorses. The study involved monitoring 33 racehorses aged 3 years in 3 imaging sessions over a period of 3 months. Temperature measurements of the neck and upper part of the forelimbs and hindlimbs from both sides were taken just before and after training. Three regions of interest (ROIs) located at the base of the neck, elbow and quarter on both sides of the body were analysed. Before physical effor...
Could Serum Collectin-11, surfactant protein-A and D be suitable biomarkers for assessing pulmonary damage caused by Rhodococcus equi infection in foals on large farms?
Polish journal of veterinary sciences    December 30, 2024   Volume 27, Issue 3 355-362 doi: 10.24425/pjvs.2024.149367
Ekinci G, Deniz O, Tüfekci E, Timur MC, Onmaz AC, Günes V, Citil M, Keles I, Hoven RVD.Rhodococcus equi (R. equi) is a primary cause of pyogranulomatous pneumonia of foals between three weeks and five months of age. Early diagnosis of rhodococcal pneumonia has always been considered a preferable approach as it can lead to more successful treatment and better outcomes. Horse stud farms where the disease is common, neonatal foals are subjected to tests such as complete blood count and fibrinogen analysis at certain intervals. However, new biomarkers are needed in addition to blood count and fibrinogen measurement in this field for early diagnosis of diseases. Based on this need, i...
Anesthesia and Myopathies of Horses.
The Veterinary clinics of North America. Equine practice    December 30, 2024   Volume 41, Issue 1 165-180 doi: 10.1016/j.cveq.2024.11.008
Castro D, Clark-Price S.Pre-existing muscle disorders in horses can often be subtle and may only become evident during or after anesthesia. Advancements in veterinary medicine, along with increased knowledge and research in this field, help minimize anesthesia-related problems. Adequate preanesthesia assessment, early disease diagnosis, and proper management are crucial in minimizing risks to the neuromuscular system during general anesthesia.
In vitro assessment of horse-isolated strains of Lactobacillus acidophilus and Ligilactobacillus equi species for fecal microbiota modulation in horses.
Journal of equine veterinary science    December 30, 2024   105341 doi: 10.1016/j.jevs.2024.105341
Nogacka AM, García A, de Los Reyes-Gavilán CG, Arboleya S, Gueimonde M.Horses are hindgut fermenters that harbor a complex intestinal microbiota (IM) which provides key enzymes aiding in the breakdown of complex carbohydrates present in their herbivorous diet. Therefore, these animals are deeply dependent on their IM for digestion and nutrition. Consequently, IM imbalances may result in alteration of fermentation patterns with impact on the animal health and the risk of disease. In this context, strategies for assisting the maintenance of a healthy IM in horses are of interest. However, there is limited research concerning the use of probiotics to improve hindgut...
Storage-related artefacts in equine blood result in a pseudo-inflammatory leukogram.
Equine veterinary journal    December 29, 2024   Volume 57, Issue 4 1074-1086 doi: 10.1111/evj.14455
Parsley AL, Hollingshead NA, Gruber EJ.To minimise storage-related artefacts, EDTA-anticoagulated whole blood should be evaluated promptly or refrigerated, a challenge in ambulatory practice. The effects of suboptimal blood storage on equine leukocyte parameters are not well-documented. Objective: Document changes in leukocyte number, automated and manual differential counts, and morphology in equine blood stored at four temperatures for up to 5 days. Methods: In vitro experimental. Methods: EDTA-anticoagulated whole blood from 13 horses was stored in a refrigerator (4°C), cooler with icepacks (3°C-19°C), room temperature (22Â...
Curcumin-loaded niosomal nanocarriers offer a promising approach to improve quality characteristics, apoptotic gene expression, and flow cytometry assessments of stallion spermatozoa after thawing.
Cryobiology    December 29, 2024   Volume 118 105188 doi: 10.1016/j.cryobiol.2024.105188
Nasiri-Foomani N, Hassani S, Najafi M, Samadi F.The optimization of cryopreservation media to reduce oxidative damage on post-thaw spermatozoa is crucial. This research aimed to assess the antioxidant properties of curcumin-loaded niosomal nanocarriers (CurLNN) on the functional characteristics, the relative expression of apoptotic genes, and flow cytometry assessments of apoptotic-like changes, reactive oxygen species production (ROS), mitochondrial membrane potential, and chromatin integrity in stallion spermatozoa following thawing. Twenty-five ejaculates were diluted in INRA96 freezing media supplemented with 20 μM of either curcumin ...
Foals born alive from mares with ultrasonographically assessed placental abnormalities: Neonatal health and development up to weaning compared to foals from healthy mares.
Theriogenology    December 29, 2024   Volume 235 31-38 doi: 10.1016/j.theriogenology.2024.12.025
Debes L, Venner M, Koether K, Vervuert I, Blanco M, Sieme H, Sielhorst J.Little is known about the health status of foals born alive from mares treated for placental disease. The aims of the present study were (1) to compare the neonatal health status and health development during the rearing period of foals born from mares treated for ultrasonographically assessed placental abnormalities (UPA) to age-matched healthy foals from the same warmblood stud and (2) analyze the influence of mare's placental health on colostrum quality. Foals (n = 127) born from mares with UPA (UPA group; P) in 2017-2019 were compared to 127 foals born from healthy mares (control group; ...
Social Relationships of Captive Bachelor Przewalski’s Horses and Their Effect on Daily Activity and Space Use.
Animals : an open access journal from MDPI    December 28, 2024   Volume 15, Issue 1 53 doi: 10.3390/ani15010053
Nykonenko A, Moturnak Y, McLoughlin PD.Understanding social relationships in at-risk species held in captivity is vital for their welfare and potential reintroduction. In social species like the Przewalski's horse (), daily time allocation and space use may be influenced by social structure and, in turn, reflect welfare. Here, we identify social relationships, time budgets, and spatial distribution of a group of nine older (aged 6-21 years) male Przewalski's horses living in a non-breeding (bachelor) group. We conducted our work at the Askania-Nova Biosphere Reserve, over 65 h of observation in summer, 2015. Horses formed stronger ...
The rhythm of horse gaits.
Annals of the New York Academy of Sciences    December 28, 2024   doi: 10.1111/nyas.15271
Laffi L, Raimondi T, Ferrante C, Pagliara E, Bertuglia A, Briefer EF, Gamba M, Ravignani A.What makes animal gaits so audibly rhythmic? To answer this question, we recorded the footfall sound of 19 horses and quantified the rhythmic differences in the temporal structure of three natural gaits: walk, trot, and canter. Our analyses show that each gait displays a strikingly specific rhythmic pattern and that all gaits are organized according to small-integer ratios, those found when adjacent temporal intervals are related by a mathematically simple relationship of integer numbers. Walk and trot exhibit an isochronous structure (1:1)-similar to a ticking clock-while canter is characteri...
Prevalence, Associated Risk Factors, and Identification of the Genera of Equine Strongyles in Horses and Donkeys in and Around Bishoftu, Ethiopia.
Veterinary medicine international    December 28, 2024   Volume 2024 3224113 doi: 10.1155/vmi/3224113
Mulaw Berihun A, Bizu F, Maru M, Kassaw S.Equines play a significant role in the economy of the country. Besides their importance, equines face several challenges mainly helminth infections. Of these strongyle parasites are the most common, particularly in the study area. Thus, a cross-sectional study was conducted from February 2022 to July 2022 to determine the prevalence and associated risk factors and to identify the genera of equine strongyle parasites in and around Bishoftu. A total of 364 equines were randomly selected from five different areas and subjected to coprological examination using the floatation technique to detect s...
Phosphorylation of SNW1 protein associated with equine melanocytic neoplasm identified in serum and feces.
Scientific reports    December 28, 2024   Volume 14, Issue 1 30842 doi: 10.1038/s41598-024-81338-6
Vinijkumthorn R, Kingkaw A, Yanyongsirikarn P, Phaonakrop N, Roytrakul S, Vongsangnak W, Tesena P.Equine melanocytic neoplasm (EMN) represents a form of skin tumor observed predominantly in grey horses aged over 15 years. Despite its prevalence, current therapeutic and preventive strategies for EMN have been subject to limited investigation. This study endeavors to shed light on potential phosphoproteins present in equine serum and fecal samples, potentially linked to EMN, with a specific focus on functional interactions in EMN pathogenesis. We examined 50 samples (25 serum, 25 feces), divided into three groups based on EMN severity: normal (n = 16), mild (n = 18), and severe EMN (...