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Oikonomidis IL, Brozos C, Tsouloufi TK, Kiossis E, Kritsepi-Konstantinou M. A comparison study between the Siemens ADVIA 120 and manual method for the differential white blood cell count in goats. Vet Clin Pathol 2024; 53:57-62. [PMID: 38395432 DOI: 10.1111/vcp.13337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 10/11/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Although widely used, the ADVIA 120 hematology analyzer has not been previously validated for determining the differential leukocyte count in goats. OBJECTIVES The aim of this study was to compare the differential leukocyte counts provided by the ADVIA 120 (A-diff) and the manual method (M-Diff) in goats. METHODS EDTA blood samples that were analyzed within 4 h of collection were used in the study. The following exclusion criteria were applied: inappropriately filled tubes or tubes containing clots, erroneous ADVIA peroxidase cytograms, and blood smears of poor quality. The A-Diff was compared with the M-Diff performed by two independent observers on 200 leukocytes. RESULTS Forty samples were included after previously excluding eight samples. The correlation between the A-Diff and M-Diff was very strong for eosinophils (r = .870, p < .001) and strong for lymphocytes (r = .796, p < .001) and neutrophils (r = .730, p < .001), while no significant correlation was observed for monocytes (r = .026, p = .872). The Passing-Bablok regression analyses revealed statistically significant constant errors for neutrophils (5.83%; 95% confidence interval [CI]: 0.41%, 12.18%) and eosinophils (1.89%; 95% CI: 1.17%, 2.71%). Bland-Altman analyses showed a statistically significant negative bias for lymphocytes (-5.0%) and a statistically significant positive bias for eosinophils (2.2%). The very low basophil percentages precluded a meaningful method comparison. CONCLUSIONS The ADVIA 120 overall demonstrated good performance for the differential WBC count in goats under the conditions of this study. Therefore, it can be considered suitable for routine hematologic screening in goats. Nonetheless, it should be emphasized that any abnormal result should be confirmed with a blood smear evaluation.
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Affiliation(s)
- Ioannis L Oikonomidis
- Department of Veterinary Anatomy, Physiology and Pathology, Institute of Infection, Veterinary and Ecological Studies, University of Liverpool, Liverpool, UK
- Diagnostic Laboratory, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Brozos
- Farm Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodora K Tsouloufi
- Diagnostic Laboratory, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelos Kiossis
- Farm Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Kritsepi-Konstantinou
- Diagnostic Laboratory, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Athanasiou LV, Tsokana CN, Gougoulis DA, Tzivara AH, Dedousi A, Katsoulos PD. Natural Co-Exposure to Borrelia burgdorferi s.l. and Anaplasma phagocytophilum: Unraveling the Hematological Profile in Sheep. Life (Basel) 2023; 13:life13020469. [PMID: 36836826 PMCID: PMC9959091 DOI: 10.3390/life13020469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/28/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
The occurrence of co-infected hosts and questing ticks with more than one tick-borne pathogen-as in the case of Anaplasma phagocytophilum and Borrelia burgdorferi sensu lato-is expected in endemic regions. Their synergy-in terms of pathogenesis and disease severity-has been suggested previously in humans. Limited data exist on the clinicopathological alterations in co-infected sheep. In this study, we investigated the impact of A. phagocytophilum and B. burgdorferi s.l. seropositivity, alone and in combination, on the hematological parameters of naturally infected sheep. A complete blood count was performed, and indirect immunofluorescence assays were used to detect IgG antibodies against A. phagocytophilum and IgG and IgM antibodies against B. burgdorferi s.l. Single natural exposure to B. burgdorferi s.l. was characterized by low Packed Cell Volume (PCV) values and platelet (PLT) counts, while single exposure to A. phagocytophilum was characterized by low PCV values, low white blood cell (WBC) counts, and an increased risk for leukopenia and neutropenia. Co-exposure resulted in the most severe blood abnormalities; all the blood parameters decreased, and the sheep presented an increased risk for anemia. Our study showed that natural co-exposure to A. phagocytophilum and B. burgdorferi s.l. in sheep leads to more severe blood abnormalities and enhances the pathogenic processes. More studies are needed to clarify the possible background mechanisms.
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Affiliation(s)
- Labrini V. Athanasiou
- Clinic of Medicine, Faculty of Veterinary Medicine, University of Thessaly, 43100 Karditsa, Greece
- Correspondence: ; Tel.: +30-24410-66-009; Fax: +30-24410-66-053
| | - Constantina N. Tsokana
- Clinic of Medicine, Faculty of Veterinary Medicine, University of Thessaly, 43100 Karditsa, Greece
| | - Dimitris A. Gougoulis
- Clinic of Medicine, Faculty of Veterinary Medicine, University of Thessaly, 43100 Karditsa, Greece
| | - Athanasia H. Tzivara
- Clinic of Medicine, Faculty of Veterinary Medicine, University of Thessaly, 43100 Karditsa, Greece
| | - Anna Dedousi
- Veterinary Research Institute, HAO-Demeter, 57001 Thessaloniki, Greece
| | - Panagiotis D. Katsoulos
- Clinic of Farm Animals, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, 54627 Thessaloniki, Greece
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Redox Status and Hematological Variables in Melatonin-Treated Ewes during Early Pregnancy under Heat Stress. Vet Sci 2022; 9:vetsci9090499. [PMID: 36136715 PMCID: PMC9505195 DOI: 10.3390/vetsci9090499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
The preovulatory follicles and preimplantation stage embryos are found to be rather sensitive to heat stress due to their low potential for scavenging reactive oxygen species (ROS). The aim of the present study was to assess the impact of melatonin administration on redox status and hematological variables during the preovulatory period and early stages of embryogenesis in heat-stressed ewes in vivo. Forty Karagouniko-breed ewes were divided in two groups, the melatonin (M, n = 20) group and control (C, n = 20) one. All animals were subjected to heat stress throughout the study, which lasted forty days (D0 to D40). In M group, melatonin implants were administered on D0. Then, oestrous synchronization was applied (D19-D33). On D34, six rams were introduced into the ewe flock for mating. Ultrasonographic examination was conducted on D73 for pregnancy diagnosis. The temperature humidity index (THI), the rectal temperature (RT), and the number of breaths per minute (BR) were evaluated twice daily. Redox biomarkers, namely total antioxidant capacity (TAC), reduced glutathione (GSH), and thiobarbituric acid reactive substances (TBARS), were assayed in blood samples collected on D0, D33, and D40. In addition, packed cell volume (PCV), white blood cells (WBCs), leukocyte differential count, and cortisol assessment were conducted in blood samples on D33 and D40. The results indicated improved fertility rate and mean number of lambs born per ewe due to improved redox status (p < 0.05) in ewes that received melatonin implants 34 days approximately before the onset of oestrus. The PCV decreased in both groups between the two time-points (p < 0.05). However, the NEU/LYMPH ratio decreased (p < 0.05) only in group M. The low cortisol levels and the decreased NEU/LYMPH ratio in both groups support the hypothesis that ewes of the indigenous Karagouniko breed may exhibit adaptation to environmental thermal stress. The administration of melatonin as an antioxidant regime may improve the reproductive competence of heat stressed ewes and may also enhance their ability to adapt at high ambient temperatures.
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Frye EA, Behling‐Kelly EL, Lejuene M, Webb JL. Complete blood count and biochemistry reference intervals for healthy adult sheep in the northeastern United States. Vet Clin Pathol 2022; 51:119-125. [DOI: 10.1111/vcp.13059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Elisha A. Frye
- Department of Population Medicine and Diagnostic Sciences Cornell University College of Veterinary Medicine Ithaca New York USA
| | - Erica L. Behling‐Kelly
- Department of Population Medicine and Diagnostic Sciences Cornell University College of Veterinary Medicine Ithaca New York USA
| | - Manigandan Lejuene
- Department of Population Medicine and Diagnostic Sciences Cornell University College of Veterinary Medicine Ithaca New York USA
| | - Julie L. Webb
- Department of Population Medicine and Diagnostic Sciences Cornell University College of Veterinary Medicine Ithaca New York USA
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Oikonomidis IL, Brozos C, Kiossis E, Tsouloufi TK, Kritsepi-Konstantinou M. A comparison study between the results of the Siemens ADVIA 120 analyzer and the manual method for differential leukocyte counts in sheep. Vet Clin Pathol 2021; 50:203-208. [PMID: 33813770 DOI: 10.1111/vcp.12935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/18/2020] [Accepted: 09/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The ADVIA 120 is a widely used hematology analyzer, which has not been previously validated for determining differential leukocyte counts in sheep. OBJECTIVES We aimed to compare differential leukocyte counts on the ADVIA 120 (A-Diff) with counts obtained using the manual method (M-Diff) in sheep. METHODS Ethylenediaminetetraacetic acid-anticoagulated blood samples analyzed within 4 hours of collection were used. Samples with inappropriately filled tubes, detectable clots, overtly erroneous ADVIA peroxidase cytograms, and poor-quality blood smears were excluded from the study. Two independent observers compared the results of the A-Diff with those of the M-Diff. The M-diff was performed by counting 200 leukocytes on a blood smear. RESULTS Overall, 88 samples (44 rams and 44 ewes) were included. The correlation between the A-Diff and M-Diff was high for neutrophils (r = .873, P < .001), lymphocytes (r = .863, P < .001), and eosinophils (r = .750, P < .001), and low for monocytes (r = .212, P = .048). The Passing-Bablok regression analyses revealed constant error for eosinophils [1.17%; 95% confidence interval (CI): 0.67%, 1.55%] and proportional error for lymphocytes (0.84; 95% CI: 0.74, 0.95) and eosinophils (0.85; 95% CI: 0.74, 0.96). The Bland-Altman analyses revealed negative biases of 2.4% and 3.0% for neutrophils and lymphocytes, respectively, and positive biases of 3.2% and 0.8% for monocytes and eosinophils, respectively. The extremely low basophil percentages precluded a meaningful method comparison for this leukocyte type. CONCLUSIONS The ADVIA 120 appears to perform well for determining neutrophil, lymphocyte, and eosinophil percentages in sheep as compared with the manual method. However, blood smear examinations are recommended for the confirmation of abnormal differential leukocyte count results.
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Affiliation(s)
- Ioannis L Oikonomidis
- School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.,The Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Roslin, UK
| | - Christos Brozos
- School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelos Kiossis
- School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodora K Tsouloufi
- School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.,The Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, Roslin, UK
| | - Maria Kritsepi-Konstantinou
- School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Athanasiou LV, Spanou VM, Katsogiannou EG, Katsoulos PD. Hematological Features in Sheep with IgG and IgM Antibodies against Borrelia burgdorferi sensu lato. Pathogens 2021; 10:pathogens10020164. [PMID: 33557024 PMCID: PMC7913760 DOI: 10.3390/pathogens10020164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 02/02/2023] Open
Abstract
Exposure of sheep to Borreliaburgdorferi sensulato (s.I.) complex, the causative agent of Lyme borreliosis (LB), has been reported in tick-abundant areas worldwide, while no data have been reported in Greece. The aim of the study was to identify the hematological alterations in sheep with seropositivity against Borrelia burgdorferi (s.I.). Blood samples were obtained from 318 tick infested sheep for blood analysis and serological determination of IgG and IgM antibodies against B. burgdorferi by indirect immunofluorescence antibody (IFA) assay after exclusion of endo-ectoparasites and other tick-borne infections. A total number of 162 sheep met the inclusion criteria, allocated in four groups based on the presence or absence of IgG and/or IgM; sheep found negative for IgM and IgG (Group A), positive for IgM (Group B), positive for both IgM and IgG (Group C) and positive for IgG (Group D). Anemia, thrombocytopenia and normal or decreased leukocyte count, mainly due to lymphopenia were the main hematological features observed in seropositive sheep. The presence of these features raises the suspicion of Borrelia infection in tick infested sheep. The seropositivity of 23.58% in sheep raises concerns of Borrelia circulation, especially in rural areas and potential risk of transmission to humans.
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Affiliation(s)
- Labrini V. Athanasiou
- Department of Medicine, Faculty of Veterinary Medicine, University of Thessaly, 43100 Karditsa, Greece; (V.M.S.); (E.G.K.)
- Correspondence: ; Tel.: +30-2441066009; Fax: +30-2441066053
| | - Victoria M. Spanou
- Department of Medicine, Faculty of Veterinary Medicine, University of Thessaly, 43100 Karditsa, Greece; (V.M.S.); (E.G.K.)
| | - Eleni G. Katsogiannou
- Department of Medicine, Faculty of Veterinary Medicine, University of Thessaly, 43100 Karditsa, Greece; (V.M.S.); (E.G.K.)
| | - Panagiotis D. Katsoulos
- Clinic of Farm Animals, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, 54627 Thessaloniki, Greece;
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Katsogiannou EG, Katsoulos PD, Christodoulopoulos G, Polizopoulou ZS, Papadakis SM, Kokkinaki KC, Billinis C, Boutsini S, Stougiou D, Athanasiou LV. Quantitative and Morphological Blood Cell Findings Associated with the Presence of Antigen and/or Antibodies Against Anaplasma phagocytophilum in Sheep. Vector Borne Zoonotic Dis 2021; 21:321-329. [PMID: 33493073 DOI: 10.1089/vbz.2020.2719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Anaplasma phagocytophilum is the causative agent of a disease known as tick borne fever in sheep, although fever is not always present. Due to inconclusive clinical signs, diagnosis is based on the cytological or molecular detection of the microorganism in blood and/or the determination of antibodies against A. phagocytophilum. The aim of the study was to determine the alterations caused by the presence of antibodies and/or the antigen of A. phagocytophilum in the blood cell count and morphology in sheep. Cytology and indirect immunofluorescence assay were performed for detection of antibodies and the antigen of A. phagocytophilum, respectively. The samples were divided into four groups depending on the result of the antigen and antibody detection. The samples that were only positive for antigen detection had mild anemia, leukopenia (lymphopenia), and thrombocytopenia. The samples that were positive in both assays had anemia, leukopenia (neutropenia and lymphopenia), and thrombocytopenia. Samples that were positive only for antibody detection had mild leukopenia. Morphological findings in infected sheep included band neutrophils, toxic neutrophils, reactive lymphocytes, and activated monocytes. The hematological findings along with cytological and serological tests can contribute to the assessment of the stage of the disease. A combination of leukopenia and thrombocytopenia raises a strong suspicion of the disease. When the microorganism and antibodies are simultaneously present, sheep are more susceptible to secondary complications. The first reported morphological findings and the quantitative hematological alterations are indicative of an inflammatory reaction, antigenic stimulation, and stress.
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Affiliation(s)
- Eleni G Katsogiannou
- Department of Medicine, Faculty of Veterinary Medicine, School of Health Sciences, University of Thessaly, Karditsa, Greece
| | - Panagiotis Dimitrios Katsoulos
- Clinic of Farm Animals, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Christodoulopoulos
- Department of Medicine, Faculty of Veterinary Medicine, School of Health Sciences, University of Thessaly, Karditsa, Greece
| | - Zoe S Polizopoulou
- Diagnostic Laboratory, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavros M Papadakis
- Department of Medicine, Faculty of Veterinary Medicine, School of Health Sciences, University of Thessaly, Karditsa, Greece
| | - Kassiopi Christina Kokkinaki
- Department of Medicine, Faculty of Veterinary Medicine, School of Health Sciences, University of Thessaly, Karditsa, Greece
| | - Charalambos Billinis
- Laboratory of Microbiology and Parasitology, Faculty of Veterinary Medicine, School of Health Sciences, University of Thessaly, Karditsa, Greece
| | - Sofia Boutsini
- National Reference Laboratory for Parasites, Directory of Veterinary Centre of Athens, Ministry of Rural Development and Food, Athens, Greece
| | - Despoina Stougiou
- National Reference Laboratory for Parasites, Directory of Veterinary Centre of Athens, Ministry of Rural Development and Food, Athens, Greece
| | - Labrini V Athanasiou
- Department of Medicine, Faculty of Veterinary Medicine, School of Health Sciences, University of Thessaly, Karditsa, Greece
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Effect of Season on Hematologic, Biochemical, and Hormonal Analytes in Rams of Two Breeds. ACTA VET-BEOGRAD 2019. [DOI: 10.2478/acve-2019-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Clinicopathological investigations are essential for the evaluation of the health status of ruminants. Apart from species-specific reference intervals, the effect of common biological factors should be considered for an accurate interpretation of laboratory data. The aim of this study was to evaluate the effect of season on hematologic and biochemical analytes, and serum total thyroxine and cortisol in adult rams of two breeds. Four blood samples (one every season) were collected from each ram. Complete blood count was performed on the Advia 120 (Siemens Healthcare Diagnostics, USA), while the differential leukocyte count was manually conducted. Biochemical and hormonal analyses were performed on Flexor E (Vital Scientific, The Netherlands), AVL 9180 (Roche Diagnostics, Belgium), and Immulite 1000 (Siemens Healthcare Diagnostics, USA), respectively. Linear mixed effects models (R language) were employed for statistical analyses. Forty-three (26 Chios, 17 Florina), adult, clinically healthy rams were included. Statistically significant (p<0.05), mostly breed-independent seasonal differences were observed in almost all of the analytes. However, when assessing these differences in view of the respective reference intervals, only a few of them were considered biologically important. Specifically, mild hyperglycemia and mild decrease in the concentration of total calcium and inorganic phosphorus were detected in winter, while a mild increase in thyroxine concentration (autumn) and creatine kinase activity (spring and summer) was also noted. In conclusion, seasonal effects should be considered when evaluating laboratory results in rams; however, season does not appear to have an essential effect on the clinicopathological profile of rams reared in the Mediterranean region.
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Oikonomidis IL, Brozos C, Kiossis E, Kritsepi-Konstantinou M. Hematologic, biochemical, hormonal, and redox status alterations during reproductive activity in adult rams of two breeds. Vet Clin Pathol 2019; 48:347-354. [PMID: 31062434 DOI: 10.1111/vcp.12731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 08/31/2018] [Accepted: 12/05/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reproduction is a crucial, energy-consuming physiologic activity, which can temporarily disturb the homeostatic balance of the organism. Although rams are commonly placed in intense breeding programs on contemporary sheep farms, the clinicopathologic and redox status alterations have not been adequately studied during reproductive activity. OBJECTIVES The objective was to investigate the clinicopathologic and redox status changes in rams during reproductive activity. METHODS Thirty-seven (19 Chios and 18 Florina breed) adult, healthy rams were individually mated with ten estrus-synchronized ewes of the same breed. Blood samples were collected prior to mating, during mating, and postmating. CBC (Advia 120), cytologic blood smear evaluation, biochemical analyses (Flexor E, AVL 9180 Electrolyte Analyzer), and thyroxine measurements (Immulite 1000) were performed. The reactive oxygen metabolites (d-ROMs) test, the biological antioxidant potential (BAP) test, and oxidative stress index were used to assess redox status. The linear mixed effects model (statistical language R) was used for statistical analyses. RESULTS Many, mostly breed-independent, clinicopathologic changes were detected during reproductive activity. Conversely, redox status alterations were found to be breed-dependent. CONCLUSIONS Intense reproductive activity was related to mild, acute muscle damage in both breeds and mild oxidative stress in Florina rams, whereas Chios rams exhibited oxidative stress resistance. The observed clinicopathologic and redox status alterations were generally consistent with those reported during various forms of physical activity and exercise in animals and humans. Intense reproductive activity does not seem to be physiologically innocuous; however, it appears to be a relatively mild muscle-damaging physical activity.
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Affiliation(s)
- Ioannis L Oikonomidis
- Diagnostic Laboratory, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Brozos
- Farm Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelos Kiossis
- Farm Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Kritsepi-Konstantinou
- Diagnostic Laboratory, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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