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Nelson VK, Nuli MV, Ausali S, Gupta S, Sanga V, Mishra R, Jaini PK, Madhuri Kallam SD, Sudhan HH, Mayasa V, Abomughaid MM, Almutary AG, Pullaiah CP, Mitta R, Jha NK. Dietary anti-inflammatory and anti-bacterial medicinal plants and its compounds in bovine mastitis associated impact on human life. Microb Pathog 2024; 192:106687. [PMID: 38750773 DOI: 10.1016/j.micpath.2024.106687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/25/2024] [Accepted: 05/12/2024] [Indexed: 05/31/2024]
Abstract
Bovine mastitis (BM) is the most common bacterial mediated inflammatory disease in the dairy cattle that causes huge economic loss to the dairy industry due to decreased milk quality and quantity. Milk is the essential food in the human diet, and rich in crucial nutrients that helps in lowering the risk of diseases like hypertension, cardiovascular diseases and type 2 diabetes. The main causative agents of the disease include various gram negative, and positive bacteria, along with other risk factors such as udder shape, age, genetic, and environmental factors also contributes much for the disease. Currently, antibiotics, immunotherapy, probiotics, dry cow, and lactation therapy are commonly recommended for BM. However, these treatments can only decrease the rise of new cases but can't eliminate the causative agents, and they also exhibit several limitations. Hence, there is an urgent need of a potential source that can generate a typical and ideal treatment to overcome the limitations and eliminate the pathogens. Among the various sources, medicinal plants and its derived products always play a significant role in drug discovery against several diseases. In addition, they are also known for its low toxicity and minimum resistance features. Therefore, plants and its compounds that possess anti-inflammatory and anti-bacterial properties can serve better in bovine mastitis. In addition, the plants that are serving as a food source and possessing pharmacological properties can act even better in bovine mastitis. Hence, in this evidence-based study, we particularly review the dietary medicinal plants and derived products that are proven for anti-inflammatory and anti-bacterial effects. Moreover, the role of each dietary plant and its compounds along with possible role in the management of bovine mastitis are delineated. In this way, this article serves as a standalone source for the researchers working in this area to help in the management of BM.
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Affiliation(s)
- Vinod Kumar Nelson
- Center for global health research, saveetha medical college, saveetha institute of medical and technical sciences, India.
| | - Mohana Vamsi Nuli
- Raghavendra Institute of Pharmaceutical Education and Research, Anantapur, India
| | - Saijyothi Ausali
- College of Pharmacy, MNR higher education and research academy campus, MNR Nagar, Sangareddy, 502294, India
| | - Saurabh Gupta
- Department of Biotechnology, GLA University, Mathura, Uttar Pradesh, India
| | - Vaishnavi Sanga
- Raghavendra Institute of Pharmaceutical Education and Research, Anantapur, India
| | - Richa Mishra
- Department of Computer Engineering, Faculty of Engineering and Technology, Parul University, Vadodara, 391760, Gujrat, India
| | - Pavan Kumar Jaini
- Department of Pharmaceutics, Raffles University, Neemrana, Rajasthan, India
| | - Sudha Divya Madhuri Kallam
- Department of Pharmaceutical Sciences, Vignan's Foundation for Science, Technology & Research (Deemed to be University), Guntur, Vadlamudi, Andhra Pradesh, 522213, India
| | - Hari Hara Sudhan
- Raghavendra Institute of Pharmaceutical Education and Research, Anantapur, India
| | - Vinyas Mayasa
- GITAM School of Pharmacy, GITAM University Hyderabad Campus, Rudraram, India
| | - Mosleh Mohammad Abomughaid
- Department of Medical Laboratory Sciences, College of Applied Medical Sciences, University of Bisha, Bisha, 61922, Saudi Arabia
| | - Abdulmajeed G Almutary
- Department of Biomedical Sciences, College of Health Sciences, Abu Dhabi University, Abu Dhabi, P.O. Box, 59911, United Arab Emirates
| | - Chitikela P Pullaiah
- Department of Chemistry, Siddha Central Research Institute, Chennai, Tamil Nadu, 60016, India
| | - Raghavendra Mitta
- Department of Pharmaceutical Sciences, Vignan's Foundation for Science, Technology & Research (Deemed to be University), Vadlamudi, Guntur, 522213, Andhra Pradesh, India
| | - Niraj Kumar Jha
- Department of Biotechnology, Sharda School of Engineering & Technology (SSET), Sharda University, Greater Noida, India; School of Bioengineering & Biosciences, Lovely Professional University, Phagwara, 144411, India; Department of Biotechnology, School of Applied & Life Sciences (SALS), Uttaranchal University, Dehradun, 248007, India.
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Pegolo S, Giannuzzi D, Piccioli-Cappelli F, Cattaneo L, Gianesella M, Ruegg PL, Trevisi E, Cecchinato A. Blood biochemical changes upon subclinical intramammary infection and inflammation in Holstein cattle. J Dairy Sci 2023; 106:6539-6550. [PMID: 37479572 DOI: 10.3168/jds.2022-23155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/20/2023] [Indexed: 07/23/2023]
Abstract
The aim of this study was to investigate the associations between subclinical intramammary infection (IMI) from different pathogens combined with inflammation status and a set of blood biochemical traits including energy-related metabolites, indicators of liver function or hepatic damage, oxidative stress, inflammation, innate immunity, and mineral status in 349 lactating Holstein cows. Data were analyzed with a linear model including the following fixed class effects: days in milk, parity, herd, somatic cell count (SCC), bacteriological status (positive and negative), and the SCC × bacteriological status interaction. Several metabolites had significant associations with subclinical IMI or SCC. Increased SCC was associated with a linear decrease in cholesterol concentrations which ranged from -2% for the class ≥50,000 and <200,000 cells/mL to -11% for the SCC class ≥400,000 cells/mL compared with the SCC class <50,000 cells/mL. A positive bacteriological result was associated with an increase in bilirubin (+24%), paraoxonase (+11%), the ratio paraoxonase/cholesterol (+9%), and advanced oxidation protein product concentration (+23%). Increased SCC were associated with a linear decrease in ferric reducing antioxidant power concentrations ranging from -3% for the class ≥50,000 and <200,000 cells/mL to -9% for the SCC class ≥400,000 cells/mL (respect to the SCC class <50,000 cells/mL). A positive bacteriological result was associated with an increase in haptoglobin concentrations (+19%). Increased SCC were also associated with a linear increase in haptoglobin concentrations, which ranged from +24% for the class ≥50,000 and <200,000 cells/mL (0.31 g/L) to +82% for the SCC class ≥400,000 cells/mL (0.45 g/L), with respect to the SCC class <50,000 cells/mL (0.25 g/L). Increased SCC were associated with a linear increase in ceruloplasmin concentrations (+15% for SCC ≥50,000 cells/mL). The observed changes in blood biochemical markers, mainly acute phase proteins and oxidative stress markers, suggest that cows with subclinical IMI may experience a systemic involvement.
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Affiliation(s)
- S Pegolo
- Department of Agronomy, Food, Natural Resources, Animals and Environment (DAFNAE), University of Padova, 35020 Legnaro, Padova, Italy
| | - D Giannuzzi
- Department of Agronomy, Food, Natural Resources, Animals and Environment (DAFNAE), University of Padova, 35020 Legnaro, Padova, Italy.
| | - F Piccioli-Cappelli
- Department of Animal Science, Food and Nutrition (DIANA) and the Romeo and Enrica Invernizzi Research Center for Sustainable Dairy Production (CREI), Faculty of Agricultural, Food and Environmental Sciences, Università Cattolica del Sacro Cuore, 29122 Piacenza, Italy
| | - L Cattaneo
- Department of Animal Science, Food and Nutrition (DIANA) and the Romeo and Enrica Invernizzi Research Center for Sustainable Dairy Production (CREI), Faculty of Agricultural, Food and Environmental Sciences, Università Cattolica del Sacro Cuore, 29122 Piacenza, Italy
| | - M Gianesella
- Department of Animal Medicine, Production and Health (MAPS), University of Padova, 35020 Legnaro, Padova, Italy
| | - P L Ruegg
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Michigan State University, East Lansing, MI 48824
| | - E Trevisi
- Department of Animal Science, Food and Nutrition (DIANA) and the Romeo and Enrica Invernizzi Research Center for Sustainable Dairy Production (CREI), Faculty of Agricultural, Food and Environmental Sciences, Università Cattolica del Sacro Cuore, 29122 Piacenza, Italy
| | - A Cecchinato
- Department of Agronomy, Food, Natural Resources, Animals and Environment (DAFNAE), University of Padova, 35020 Legnaro, Padova, Italy
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Paramasivam R, Gopal DR, Dhandapani R, Subbarayalu R, Elangovan MP, Prabhu B, Veerappan V, Nandheeswaran A, Paramasivam S, Muthupandian S. Is AMR in Dairy Products a Threat to Human Health? An Updated Review on the Origin, Prevention, Treatment, and Economic Impacts of Subclinical Mastitis. Infect Drug Resist 2023; 16:155-178. [PMID: 36636377 PMCID: PMC9831082 DOI: 10.2147/idr.s384776] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
Background Bovine mastitis is the most frequent and costly illness impacting dairy herds worldwide. The presence of subclinical mastitis in dairy cows has an impact on the decreased output of milk and milk quality, culling of affected cows, mortality rate, as well as mastitis-related treatment expenses, generating significant financial loss to the dairy industry. The pathogenic bacteria invade through the mammary gland, which then multiply in the milk-producing tissues causing infection, and the presence of pathogenic bacteria in milk is concerning, jeopardizes human health, and also has public health consequences. Intervention to promote herd health is essential to protect public health and the economy. Results This review attempts to provide an overview of subclinical mastitis, including mastitis in different species, the effect of mastitis on human health and its pathogenic mechanism, the prevalence and incidence of subclinical mastitis, and current preventive, diagnostic, and treatment methods for subclinical mastitis. It also elaborates on the management practices that should be followed by the farms to improve herd immunity and health. Conclusion This review brings the importance of the threat of antimicrobial resistance organisms to the dairy industry. Furthermore, this review gives a glimpse of the economic consequences faced by the farmers and a futuristic mastitis market analysis in the dairy industry.
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Affiliation(s)
- Ragul Paramasivam
- Research and Development Division, Chimertech Private Limited, Chennai, India
| | - Dhinakar Raj Gopal
- Department of Animal Biotechnology, Madras Veterinary College, Tamilnadu Veterinary and Animal Science University (TANUVAS), Chennai, 600007, India
| | | | | | | | - Bhavadharani Prabhu
- Research and Development Division, Chimertech Private Limited, Chennai, India
| | - Veeramani Veerappan
- Research and Development Division, Chimertech Private Limited, Chennai, India
| | | | | | - Saravanan Muthupandian
- AMR and Nanotherapeutics Lab, Centre for Transdisciplinary Research (CFTR), Department of Pharmacology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Chennai, India,Division of Biomedical Science, College of Health Sciences, School of Medicine, Mekelle University, Mekelle, Ethiopia,Correspondence: Saravanan Muthupandian, Email
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Sharun K, Dhama K, Tiwari R, Gugjoo MB, Iqbal Yatoo M, Patel SK, Pathak M, Karthik K, Khurana SK, Singh R, Puvvala B, Amarpal, Singh R, Singh KP, Chaicumpa W. Advances in therapeutic and managemental approaches of bovine mastitis: a comprehensive review. Vet Q 2021; 41:107-136. [PMID: 33509059 PMCID: PMC7906113 DOI: 10.1080/01652176.2021.1882713] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Mastitis (intramammary inflammation) caused by infectious pathogens is still considered a devastating condition of dairy animals affecting animal welfare as well as economically incurring huge losses to the dairy industry by means of decreased production performance and increased culling rates. Bovine mastitis is the inflammation of the mammary glands/udder of bovines, caused by bacterial pathogens, in most cases. Routine diagnosis is based on clinical and subclinical forms of the disease. This underlines the significance of early and rapid identification/detection of etiological agents at the farm level, for which several diagnostic techniques have been developed. Therapeutic regimens such as antibiotics, immunotherapy, bacteriocins, bacteriophages, antimicrobial peptides, probiotics, stem cell therapy, native secretory factors, nutritional, dry cow and lactation therapy, genetic selection, herbs, and nanoparticle technology-based therapy have been evaluated for their efficacy in the treatment of mastitis. Even though several strategies have been developed over the years for the purpose of managing both clinical and subclinical forms of mastitis, all of them lacked the efficacy to eliminate the associated etiological agent when used as a monotherapy. Further, research has to be directed towards the development of new therapeutic agents/techniques that can both replace conventional techniques and also solve the problem of emerging antibiotic resistance. The objective of the present review is to describe the etiological agents, pathogenesis, and diagnosis in brief along with an extensive discussion on the advances in the treatment and management of mastitis, which would help safeguard the health of dairy animals.
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Affiliation(s)
- Khan Sharun
- Division of Surgery, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Ruchi Tiwari
- Department of Veterinary Microbiology and Immunology, College of Veterinary Sciences, Deen Dayal Upadhayay Pashu Chikitsa Vigyan Vishwavidyalay Evum Go-Anusandhan Sansthan (DUVASU), Mathura, India
| | - Mudasir Bashir Gugjoo
- Division of Veterinary Clinical Complex, Faculty of Veterinary Sciences & Animal Husbandry, Sher-E-Kashmir University of Agricultural Sciences and Technology of Kashmir, Shalimar, Srinagar, Jammu and Kashmir, India
| | - Mohd Iqbal Yatoo
- Sher-E-Kashmir University of Agricultural Sciences and Technology of Kashmir, Shalimar, Srinagar, Jammu and Kashmir, India
| | - Shailesh Kumar Patel
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Mamta Pathak
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Kumaragurubaran Karthik
- Central University Laboratory, Tamil Nadu Veterinary and Animal Sciences University, Chennai, Tamil Nadu, India
| | | | - Rahul Singh
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Bhavani Puvvala
- Rajiv Gandhi Institute of Veterinary Education and Research, Kurumbapet, Puducherry, India
| | - Amarpal
- Division of Surgery, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Rajendra Singh
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Karam Pal Singh
- Division of Surgery, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India
| | - Wanpen Chaicumpa
- Center of Research Excellence on Therapeutic Proteins and Antibody Engineering, Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Esmaeilnejad B, Dalir-Naghadeh B, Tavassoli M, Asri-Rezaei S, Mahmoudi S, Rajabi S, Aligolzadeh A, Akbari H, Morvaridi A. Assessment of hepatic oxidative damage, paraoxonase-1 activity, and lipid profile in cattle naturally infected with Ba7besia bigemina. Trop Anim Health Prod 2021; 53:219. [PMID: 33751256 DOI: 10.1007/s11250-021-02662-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/14/2021] [Indexed: 11/27/2022]
Abstract
Naturally occurring Babesia bigemina infection in cattle is associated with changes in the status of oxidative stress, trace elements, sialic acid, and cholinesterase activity in blood. However, to date there is no description of hepatic damage in the infected animals. More importantly, the majority of the above-mentioned causative factors are synthesized or stored in the liver. Therefore, this study was undertaken to evaluate biomarkers of hepatic function, paraoxonase-1 activity, and lipid profile in 13 cattle infected with B. bigemina which did not respond to standard treatment. The animals were necropsied and the histopathology of the liver and DNA damage of hepatocytes were examined. Blood analysis revealed a significant parasitemia burden-dependent increase in the activities of hepatic enzymes and total bilirubin and a decrease in albumin concentrations in the infected cattle compared to the control ones. Paraoxonase-1 activity was remarkably lower in the infected animals than the control. A significant decrease in the blood concentrations of total cholesterol, low density lipoprotein, and high density lipoprotein and a significant increase in the triglyceride concentration were observed in the infected animals. Severe oxidative damages were also recorded in the haptic tissue evidenced by significant alterations in the activities of antioxidant enzymes, suppression of total antioxidant capacity, and oxidation of biomolecules. Congestion of blood vessels, bile duct hyperplasia, and hepatocyte necrosis were the evident histopathologic findings. Our results revealed significant changes in the indices of liver function in the diseased cattle, leading to the conclusion that the parasite can potentially cause liver dysfunction.
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Affiliation(s)
- Bijan Esmaeilnejad
- Department of Pathobiology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran.
| | - Bahram Dalir-Naghadeh
- Department of Internal Medicine and Clinical Pathology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
| | - Mousa Tavassoli
- Department of Pathobiology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
| | - Siamak Asri-Rezaei
- Department of Internal Medicine and Clinical Pathology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
| | - Soraya Mahmoudi
- Department of Pathobiology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
| | - Sepideh Rajabi
- Department of Pathobiology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
| | - Armin Aligolzadeh
- Department of Pathobiology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
| | - Hamid Akbari
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran
| | - Asghar Morvaridi
- Department of Pathobiology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
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Folnožić I, Samardžija M, Đuričić D, Vince S, Perkov S, Jelušić S, Valpotić H, Ljubić BB, Lojkić M, Gračner D, Žaja IŽ, Maćešić N, Grizelj J, Dobranić T, Redžepi G, Šostar Z, Turk R. Effects of in-feed clinoptilolite treatment on serum metabolic and antioxidative biomarkers and acute phase response in dairy cows during pregnancy and early lactation. Res Vet Sci 2019; 127:57-64. [PMID: 31678454 DOI: 10.1016/j.rvsc.2019.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 11/29/2022]
Abstract
The objective of this study was to evaluate the effects of in-feed clinoptilolite (CPL) on serum metabolic and antioxidative biomarkers, acute phase proteins and reproductive performance in cows during pregnancy and lactation. A total of 78 Holstein-Friesian cows were randomly assigned into two groups: the treatment group, cows fed CPL (n = 38) which received 50 g of powdered CPL twice a day from day 180 before parturition to day 60 postpartum; and the control group (n = 40). Blood samples were taken on days 180, 90, 60, 30 and 10 before parturition, on day of calving and on days 5, 12, 19, 26, 33, 40 and 60 postpartum, and were analysed for metabolic biomarkers: glucose, triglycerides, total cholesterol, high density lipoprotein cholesterol, non-esterified fatty acids, beta-hydroxybutyrate (BHB), antioxidative biomarkers and acute phase proteins: paraoxonase-1 (PON1), apolipoprotein A-I, haptoglobin (Hp) and serum amyloid A (SAA). CPL supplementation increased concentration of glucose and significantly decreased (P < .05) level of BHB during puerperium. The SAA concentration in CPL-fed cows was significantly decreased (P < .05) on days 33, 40 and 60 postpartum as well as Hp concentration on days 0 and 12 postpartum. The results of this study suggest that the CPL-fed cows may have improved metabolic status due to the tendency of greater glucose levels and decreased BHB values during early lactation. In addition, acute phase response was lower (P < .05) in CPL-fed cows. Such an outcome might be attributed to the effect of dietary CPL on intensity and severity of the negative energy balance and inflammatory response in dairy cows.
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Affiliation(s)
- Ivan Folnožić
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Marko Samardžija
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia.
| | - Dražen Đuričić
- Veterinary Practice Đurđevac, Malinov trg 7, 48350 Đurđevac, Croatia
| | - Silvijo Vince
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Sonja Perkov
- Merkur University Hospital, Zajčeva 19, 10000 Zagreb, Croatia
| | - Sanja Jelušić
- Andrija Stampar Teaching Institute for Public Health, Mirogojska 16, 10000 Zagreb, Croatia
| | - Hrvoje Valpotić
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Blanka Beer Ljubić
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Martina Lojkić
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Damjan Gračner
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Ivona Žura Žaja
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Nino Maćešić
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Juraj Grizelj
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Tomislav Dobranić
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
| | - Gzim Redžepi
- University Hospital Centre, Jordanovac, Jordanovac 104, 10000 Zagreb, Croatia
| | - Zvonimir Šostar
- Andrija Stampar Teaching Institute for Public Health, Mirogojska 16, 10000 Zagreb, Croatia
| | - Romana Turk
- Faculty of Veterinary Medicine, University of Zagreb, Heinzelova 55, 10000 Zagreb, Croatia
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