Uncommon Ehrlichia canis infection associated with morulae in neutrophils from naturally infected dogs in Brazil

Ehrlichia and Anaplasma species are the most common tick‐borne disease (TBD) pathogens in dogs worldwide. Ehrlichia canis, the aetiological agent of the Canine Monocytic Ehrlichiosis (CME), is known to replicate within the cytoplasm of mononuclear cells into clusters of organisms called morulae. However, detection of morulae in neutrophils is commonly observed in dogs infected by Ehrlichia ewingii or Anaplasma phagocytophilum. We report uncommon clinical cases of canine ehrlichiosis presenting morulae compatible with E. ewingii and A. phagocytophilum in dogs from two distinct regions of Brazil. Eight dogs were admitted to two veterinary teaching hospitals from Brazil, showing clinical or haematological signs suggestive of TBD. Blood or peritoneal fluid was withdrawn for haematological and cytologic analysis. All samples were evaluated by PCR assays for Ehrlichia and Anaplasma using genus‐specific primers for dsb, 16S rRNA and groEL genes, followed by sequencing. Samples were also evaluated by nested PCR assays for the 16S rRNA gene of E. ewingii and groEL gene of A. phagocytophilum and Anaplasma platys. Seven dogs revealed thrombocytopenia, six dogs had monocytosis and five presented lymphopenia and anaemia. All dogs showed morulae structures compatible with Ehrlichia spp. in neutrophils and were PCR‐positive for the dsb and 16S rRNA gene fragments of Ehrlichia, with sequences showing 100% identity with multiple E. canis sequences deposited in the GenBank™. Sequencing of 16S rRNA and groEL gene fragments from one PCR‐positive dog showed 100% identity with A. platys. Overall, our data suggest that in endemic regions for E. canis, that is Brazil, the presence of morulae in neutrophils may indicate infection by this bacterium. Herein, morulae were also found in neutrophils present in the peritoneal fluid of a dog. Also, this is the first report of E. canis and Hepatozoon canis co‐infection in neutrophils from naturally infected dogs confirmed by DNA sequencing.     

Cetacean morbillivirus in Southern Right Whales,Brazil

Cetacean morbillivirus (CeMV) has caused repeated epizootics and interepizootic fatalities in a variety of cetacean species worldwide. Recently, a novel CeMV strain (GD‐CeMV) was linked to a mass die‐off of Guiana dolphins (Sotalia guianensis) in Brazil. Southern right whales (SRWs; Eubalaena australis) migrate to the southern Brazilian coast during austral winter and spring (June through November) for breeding and calving. Because unexplained high calf mortality rates have recurrently been documented in SRWs, we hypothesized they could be infected with CeMV. We developed a novel real‐time RT‐PCR method based on SYBR^® GREEN for detection of CeMV and identified the virus in three out of five stranded SRWs from Santa Catarina state, Brazil. The partial sequences of the morbillivirus phosphoprotein gene suggest that the virus is similar to the GD‐CeMV strain. Our results indicate CeMV can infect SRWs and should be considered in the differential aetiologic diagnosis of infectious diseases in this species. It also raises concern for potential conservation implications for this species in its main coastal breeding area off Southern Brazil.     

Molecular,serological, pathological,immunohistochemical and microbiological investigation of Brucella spp. in marine mammals of Brazil reveals new cetacean hosts

Brucella‐exposure and infection is increasingly recognized in marine mammals worldwide. To better understand the epidemiology and health impacts of Brucella spp. in marine mammals of Brazil, molecular (conventional PCR and/or real‐time PCR), serological (Rose Bengal Test [RBT], Competitive [c]ELISA, Serum Agglutination Test [SAT]), pathological, immunohistochemical (IHC) and/or microbiological investigations were conducted in samples of 129 stranded or by‐caught marine mammals (orders Cetartiodactyla [n = 124], Carnivora [n = 4] and Sirenia [n = 1]). Previous serological tests performed on available sera of 27 of the 129 animals (26 cetaceans and one manatee), indicated 10 seropositive cetaceans. Conventional PCR and/or real‐time PCR performed in cases with available organs (n = 119) and/or blood or swabs (n = 10) revealed 4/129 (3.1%) Brucella‐infected cetaceans (one of them with positive serology; the remaining three with no available sera). Pathological, IHC and/or microbiological analyses conducted in PCR/real‐time PCR and/or seropositive cases (n = 13) revealed Brucella‐type lesions, including meningitis/meningoencephalitis, pneumonia, necrotizing hepatitis, pericarditis and osteoarthritis in some of those animals, and positive IHC was found in all of them (excepting two live‐stranded animals without available organs). Brucella spp. culture attempts were unsuccessful. Our results demonstrated exposure, asymptomatic, acute and chronic Brucella sp. infection in several cetacean species in the Brazilian coast, highlighting the role of this pathogen in stranding and/or death, particularly in Clymene dolphin (Stenella clymene) and short‐finned pilot whale (Globicephala macrorhynchus) off Ceará State. Novel hosts susceptible to Brucella included the franciscana (Pontoporia blainvillei), the Guiana dolphin (Sotalia guianensis) and the spinner dolphin (Stenella longirostris). Additionally, three coinfection cases involving Brucella spp. and cetacean morbillivirus, Edwarsiella tarda and Proteus mirabilis were detected. To the best of our knowledge, this is the first long‐term and large‐scale survey of Brucella spp. in marine mammals of South America, widening the spectrum of susceptible hosts and geographical distribution range of this agent with zoonotic potential.     

Brucella canis infection in dogs from commercial breeding kennels in Brazil

Canine brucellosis caused by Brucella canis is a neglected zoonosis worldwide and is a leading cause of reproductive failure in dogs, often causing substantial economic losses in breeding kennels. This study aimed to investigate the occurrence of B. canis infection in dogs of commercial breeding kennels located in São Paulo State, Brazil. A total of 753 dogs (183 males and 570 females) from 38 commercial kennels were clinically examined, and blood samples were collected for brucellosis diagnosis through blood culture. The association between clinical manifestations suggestive of brucellosis and positive results through blood culture was determined. Of the 753 dogs tested, 166 (22.0%) had at least one clinical sign suggestive of brucellosis and 158 (20.9%) had positive blood cultures. Seventy‐two dogs had positive blood culture and had at least one clinical sign suggestive of brucellosis, while 91 dogs showed at least one clinical manifestation suggestive of brucellosis although blood culture was negative. Of the 38 kennels, 16 (42.1%) had at least one positive dog. The prevalence of infection in each kennel varied from 3.8% to 62.6%. Abortion/stillbirth, failure to conceive and enlargement of lymph nodes were significantly associated with brucellosis in female. No association of clinical signs and positive results in blood culture was observed in males. None of the kennels has been carrying out programmes to control brucellosis, and the sale of infected dogs was considered a common practice yielding risks to the public health, in view of the zoonotic potential of the infection.     

Non‐tuberculous Mycobacteria in Wild Boar (Sus scrofa) from Southern Spain: Epidemiological,Clinical and Diagnostic Concerns

Non‐tuberculous mycobacteria (NTM) are widely distributed in the environment, particularly in wet soil, marshland, rivers or streams, but also are causative agents of a wide variety of infections in animals and humans. Little information is available regarding the NTM prevalence in wildlife and their effects or significance in the bovine tuberculosis (bTB) epidemiology and diagnosis. This research shows the most frequently NTM isolated in lymph nodes of wild boar (Sus scrofa) from southern Spain, relating the NTM presence with the individual characteristics, the management of animals and the possible misdiagnosis of Mycobacterium bovis in concurrent infections. A total of 219 NTM isolates were obtained from 1249 wild boar mandibular lymph nodes sampled between 2007 and 2011. All but 75 isolates were identified by the PCR‐restriction analysis‐hsp65, and a partial sequencing of the 16S rDNA was carried out to identify the rest of the isolates. Results showed that Mycobacterium chelonae was the most frequently isolated NTM specie (133 isolates, 60.7%), followed by Mycobacterium avium (24 isolates, 11%). No relation was found regarding sex, body condition and management, but M. chelonae was more frequently detected in adults, whereas M. avium was more prevalent in subadults. The high NTM prevalence observed in the studied wild boar populations could make difficult the bTB diagnostic.     

Seroepidemiology of ovine toxoplasmosis and neosporosis in breeding rams from Rio Grande do Sul,Brazil

This study determined the prevalence of ovine toxoplasmosis and neosporosis and the risk factors associated with the development of these diseases in breeding rams from the State of Rio Grande do Sul (RS), Southern Brazil. Serum samples (n = 1,800) from breeding rams maintained on 705 sheep farms from seven mesoregions were evaluated serologically to detect anti‐IgG Toxoplasma gondii by indirect ELISA and anti‐IgG Neospora caninum by the indirect immunofluorescence assay (IFA). The prevalence of T. gondii was 33.05% (595/1,800); seropositivity to N. caninum was 18.44% (332/1,800). Additionally, there was simultaneous seropositivity (8.94%;161/1,800) to N. caninum and T. gondii. The variables size of the property (<500 ha) (Prevalence Ratio, PR = 1.36); breeding system (semi‐intensive/intensive) (PR = 1.23); and natural mounting without control (PR = 1.50) were considered as risk factors for the occurrence of T. gondii. Size of the property (<500 ha) (PR = 1.58) and natural mounting without control (PR = 2.32) were risk factors associated with the prevalence of N. caninum in rams. Additionally, separation of ewes prior to parturition was considered as a protective factor for the occurrence of T. gondii (PR = 0.82) and N. caninum (PR = 0.74). These results demonstrated that these two parasitic disease agents are endemic in rams throughout all regions of RS.     

Factors associated with the prevalence of antibodies against Brucella abortus in water buffaloes from Santarém,Lower Amazon region,Brazil

We evaluated the factors associated with the prevalence of antibodies against Brucella abortus in buffaloes in the municipality of Santarém, Western Pará, northern Brazil. The study was conducted on 60 farms, representing 25.8% of the total buffalo farms in the region. From those farms, a total of 426 buffaloes were sampled, males of any age and females more than 24 months of age, to avoid a false‐positive reaction in the serological test due to vaccination. The Acidified Agglutination Serum Test was carried out on serum samples using B. abortus strain 1,119–3 as the antigen. Univariate and multivariate analysis were performed to investigate the association between brucellosis and potential risk factors. Of the 426 tested buffaloes, 29 were positive, resulting in an overall animal prevalence of antibodies against B. abortus at the animal level of 6.8% (4.6–9.6; 95% confidence interval). The herd level prevalence was 30% (18 of 60) and seroprevalence range within farms was from 0% to 100%. At the animal level, buffaloes raised in the floodplains tended (p = 0.06) to present a higher seroprevalence (9.70%) of antibodies against B. abortus than buffaloes raised in dry land (4.98%) and cows tended (p = 0.054) to have a higher seroprevalence than male buffaloes. Multivariate herd‐level analysis revealed association between farm type and brucellosis seroprevalence (p = 0.015); dairy farms were two times more likely to have seropositive buffalo than beef farms. Our survey demonstrated a high farm seroprevalence of B. abortus in buffalo raised in an Amazonian ecosystem with positive animals found in one third of sampled farms.     

Testicular lesions and epididymal sperm parameters in the Iranian river buffalo (Bubalus bubalis)

The aim of this study was to evaluate the testicular lesions and their effects on the epididymal sperm parameters in the Iranian river buffalo (Bubalus bubalis). Total numbers of 117 scrota from the pubertal buffalo were provided from the local slaughterhouse. The samples were evaluated for morphological parameters and any macro‐ or microscopic lesions. The sterile swabs from the testis parenchyma were subjected to microbiology culture. The epididymal spermatozoon was analysed for concentration, progressive motility and abnormalities. The results showed 34.2% fibrotic adhesions between parietal and visceral layers of tunica vaginalis that was significantly different among seasons (P < 0.05). The cases of unilateral cryptorchidism and bilateral Sertoli cell tumour were detected, with no spermatozoa in the respected epididymides. Microscopic examination showed 13.25% (31/234) lesions including general (51.61%; 16/31) and multifocal (29.03%; 9/31) degenerations as well as interstitial orchitis (9.68%; 3/31) and the Sertoli cell tumour (6.45%; 2/31). No relationship between the lesions and the bacterial isolation (n = 6) was detected. The sperm parameters and morphological parameters of the testis were under influence of microscopic lesions (P < 0.05). In conclusion, the testicular macro‐ and microscopic lesions may have a noticeable contribution in the Iranian buffalo fertility.     

Factors associated with the prevalence of antibodies against Theileria equi in equids of Western Pará, Brazil

The State of Pará has one of the largest herds of equids (horse, donkey and mule) in Brazil, most of these animals are found on cattle farms. Equine theileriosis is a tick‐borne disease caused by the parasite Theileria equi and is characterized by fever, anaemia, icterus, intravascular haemolysis, haemoglobinuria, spleen and hepatomegaly, and even death. The present study aimed to determine the prevalence of antibodies against T. equi in equids in the western region of the State of Pará, Brazil, and to identify potential risk factors associated with parasite infection. A cross‐sectional study was conducted with cluster sampling of farm horses from 18 municipalities. In the cities visited, samples from sport and carthorses were also included. Serum was obtained to detect T. equi‐specific antibodies using an indirect enzyme‐linked immunosorbent assay (iELISA) based on a crude parasite antigen. In order to identify possible risk factors of the infection which are associated with the prevalence of antibodies, a chi‐squared test was carried out. Of 1,117 equids, 373 tested positive for T. equi antibodies with an overall prevalence of 33.4% (31.3%–37.0% for the 95% confidence interval). Sex, animal species and breed were found not to be associated with the presence of T. equi antibodies, whereas age, the presence of dogs or ticks were associated with seropositivity (p < 0.05). Horses with ticks were 2.4 more likely seropositive than horses without ticks. The presence of dogs in the equid habitat and the presence of ticks resulted in a higher T. equi seropositive rate probably because dogs are hosts for vector ticks of T. equi. Our study represents the first report of T. equi antibodies in equids of western Pará revealing a widespread distribution of seropositive animals.     

Leishmaniasis in cat shelters: A serological,molecular and entomological study

An epidemiological Leishmania spp. and entomological Phlebotomine sandflies survey was performed in cat shelters at leishmaniasis endemic area of Brazil. Blood and conjunctival swab (CS) samples were collected from 94 cats in two animal protection shelters. These samples were subjected to serological tests using the indirect immunofluorescence antibody test (IFAT) and indirect enzyme‐linked immunosorbent assay (ELISA) and to molecular test by polymerase chain reaction (PCR). In addition, a Phlebotomine sandflies survey was performed in the same shelters. The analyses revealed a positivity of 31.91% (30/94) through ELISA and 29.79% (28/94) through IFAT. The two serological tests showed a positive association with perfect agreement (k = 0.925). None of the cats were positive by Leishmania spp. DNA. One Lutzomyia (Lutzomyia) longipalpis male was found in one of the cat shelters. The results and the implications of our findings are discussed below.     

Intestinal parasites including Cryptosporidium,Cyclospora, Giardia,and Microsporidia,Entamoeba histolytica,Strongyloides, Schistosomiasis,and Echinococcus: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of intestinal parasites in the pre‐ and post‐transplant period. Intestinal parasites are prevalent in the developing regions of the world. With increasing travel to and from endemic regions, changing immigration patterns, and the expansion of transplant medicine in developing countries, they are increasingly recognized as a source of morbidity and mortality in solid‐organ transplant recipients. Parasitic infections may be acquired from the donor allograft, from reactivation, or from de novo acquisition post‐transplantation. Gastrointestinal multiplex assays have been developed; some of the panels include testing for Cryptosporidium, Cyclospora, Entamoeba histolytica, and Giardia, and the performance is comparable to conventional methods. A polymerase chain reaction test, not yet widely available, has also been developed to detect Strongyloides in stool samples. New recommendations have been developed to minimize the risk of Strongyloides donor‐derived events. Deceased donors with epidemiological risk factors should be screened for Strongyloides and recipients treated if positive as soon as the results are available. New therapeutic agents and studies addressing the optimal treatment regimen for solid‐organ transplant recipients are unmet needs.     

Seroprevalence of selected flaviviruses in free‐living and captive capuchin monkeys in the state of Pernambuco,Brazil

Mosquito‐borne diseases such as dengue, yellow fever and, more recently, Chikungunya virus (CHIKV ) and Zika virus (ZIKV ) have a great impact in the public health. In addition, the presence of such viruses might have an impact on wild animal conservation as well as their possible role as animal reservoir. Here, we performed a serological survey searching for antibodies against a panel of flaviviruses [ZIKV , Dengue virus (DENV ), Yellow Fever virus (YFV ), West Nile virus (WNV ), Saint Louis Encephalitis virus (SLEV ), Ilheus virus (ILHV ) and Rocio virus (ROCV )] using plaque reduction neutralization test (PRNT ₉₀) in both free‐ranging and captive capuchin monkeys (Sapajus flavius and Sapajus libidinosus ). Captive and free‐living monkeys were sampled between June 2015 and January 2016 in the state of Pernambuco, including in the border with State of Paraíba, the epicentre of the ZIKV epidemics in Brazil. We have found neutralizing antibodies for ZIKV , DENV ‐1, DENV ‐2, DENV ‐3, DENV ‐4, YFV , ILHV and SLEV in both S . flavius and S . libidinosus samples. No positives samples were found for ROCV and WNV . Our results suggest that these flaviviruses might be circulating in capuchin monkey in the studied region. The possible presence of these viruses represents a risk for public health, as well as for animal conservation, especially for S . flavius which is a critically endangered species, facing high risk of extinction.     

Single nucleotide polymorphisms in Renalase and KCNQ1 genes and female infertility: A cross‐sectional study in Pakistan

A global increase in the incidence of subfertility is observed, and research suggests strong genetic influences that might restrict fertility directly or indirectly. It therefore becomes important to rule out the existence of genetic causes and counsel infertile couples before offering “Advanced Infertility Treatment Techniques.” This cross‐sectional study aimed to explore the association of KCNQ1 (rs2237895) and Renalase (rs2576178 and rs10887800) single nucleotide polymorphisms with different causes of infertility by analysing 508 fertile and 164 infertile women. Gene variant (AC/CC) of KCNQ1 rs2237895 showed a slight difference in the endometriosis group compared to the fertile group (p = .049), with the C allele showing a significant association with infertility overall (OR = 1.42 [1.100–1.833]; p < .0069). The variant AG/GG of Renalase rs2576178 was significantly associated with overall infertility (OR = 2.266; p < .001), with a strong G allele association with unexplained infertility OR = 2.796 (p = .002) that remained significant after adjusting for age and body mass index. Similarly, Renalase rs10887800 AG/GG and G allele showed significant association with both infertility due to polycystic ovarian syndrome and unexplained infertility. Expression of single nucleotide polymorphism rs2237895 and rs2576178 in both KCNQ1 and Renalase genes might be responsible for altering reproductive potential, hence leading to infertility in women.     

Invasive micropapillary carcinoma of the urinary bladder: An immunohistochemical study of neoplastic and stromal cells

A 66-year-old man complained of hematuria. A cystoscopy revealed a non-papillary tumor and radical cystectomy was performed. Macroscopically, an ulcerative lesion was observed. Microscopically, the neoplasm showed a mixture of urothelial carcinoma, squamous cell carcinoma and micropapillary carcinoma. Immunohistochemically, micropapillary carcinoma cells were positive for cytokeratins 7 and 20, carcinoembryonic antigen and CA125. Additionally, myofibroblasts were distributed in a chicken-wire pattern in the stroma of micropapillary carcinoma. Subsequently, the patient died of carcinoma 1 year after the onset of symptoms. Our results support the previous hypothesis that bladder micropapillary carcinoma runs an aggressive clinical course and suggest that micropapillary carcinoma may show the glandular differentiation of urothelial carcinoma and show the stromal reaction by myofibroblasts resembling that of carcinoma in other anatomic sites.     

Risk Factors and Spatial Distribution of Canine Coccidioidomycosis in California, 2005–2013

Given the predisposition of dogs to coccidioidomycosis, identification of high‐risk regions for coccidioidomycosis in dogs may improve early recognition of emerging human disease. We sought to identify risk factors for canine coccidioidomycosis and to produce a risk map for coccidioidomycosis occurrence. Forty‐one dogs seen at the Veterinary Medical Teaching Hospital at the University of California, Davis, between 2005 and 2013 with coccidioidomycosis were identified together with a control population of 79 dogs. Owners were surveyed about potential risk factors including younger age, digging behaviour, and travel to Arizona or the California central valley. Risk factors were analysed using logistic regression analysis. Outcomes were used to generate a risk map for coccidioidomycosis in California. There was a significant correlation between the reported rate of coccidioidomycosis in humans and our risk map for canine coccidioidomycosis in California, supporting the idea of dogs as sentinels for emerging geographic areas for coccidioidomycosis in humans.     

Molecular detection and genetic diversity of Bartonella species in large ruminants and associated ectoparasites from the Brazilian Cerrado

Currently, five Bartonella species and an expanding number of Candidatus Bartonella species have globally been reported in ruminants. Likewise, different Bartonella genotypes were identified. However, studies relating to ruminant‐associated Bartonella in Brazil are scarce. The current study aimed to assess the prevalence and genetic diversity of Bartonella in cattle, buffaloes and associated ectoparasites in Brazil. For this purpose, EDTA‐blood samples from 75 cattle and 101 buffaloes were sampled. Additionally, 128 Rhipicephalus microplus and one Amblyomma sculptum ticks collected from cattle, and 197 R. microplus, one A. sculptum and 170 lice (Haematopinus tuberculatus) collected from buffaloes were included. Bartonella DNA was initially screened through an HRM real‐time PCR assay targeting the 16S–23S internal transcribed spacer (ITS), and the positive samples were submitted to an additional HRM assay targeting the ssrA gene. The HRM‐positive amplicons were sequenced, and the nucleotide identity was assessed by BLASTn. Bartonella spp.‐positive DNA samples were analysed by conventional PCR assays targeting the gltA and rpoB genes, and then, the samples were cloned. Finally, the phylogenetic positioning and the genetic diversity of clones were assessed. Overall, 21 of 75 (28%) cattle blood samples and 13 of 126 (10.3%) associated ticks were positive for Bartonella bovis. Out of 101 buffaloes, 95 lice and 188 tick DNA samples, one (1%) buffalo and four (4.2%) lice were positive for Bartonella spp. Conversely, none of the ticks obtained from buffaloes were positive for Bartonella. The Bartonella sequences from buffaloes showed identity ranging from 100% (ITS and gltA) to 94% (ssrA) with B. bovis. In contrast, the Bartonella DNA sequences from lice were identical (100%) to uncultured Bartonella sp. detected in cattle tail louse (Haematopinus quadripertusus) from Israel in all amplified genes. The present study demonstrates the prevalence of new B. bovis genotypes and a cattle lice‐associated Bartonella species in large ruminants and their ectoparasites from Brazil. These findings shed light on the distribution and genetic diversity of ruminant‐ and ectoparasite‐related Bartonella in Brazil.     

The pulmonary virome,bacteriological and histopathological findings in bovine respiratory disease from western Canada

The aetiology and pathogenesis of bovine respiratory disease (BRD) are complex and involve the interplay of infectious agents, management and environmental factors. Previous studies of BRD focused on ante‐mortem samples from the upper respiratory tract and identified several unconventional viruses. The lung, however, is the primary location where significant BRD lesions are usually found and is a common post‐mortem diagnostic specimen. In this study, results of high‐throughput virome sequencing, bacterial culture, targeted real‐time PCR and histological examination of 130 bovine pneumonic lungs from western Canadian cattle were combined to explore associations of microorganisms with different types of pneumonia. Fibrinous bronchopneumonia (FBP) was the predominant type of pneumonia (46.2%, 60/130) and was associated with the detection of Mannheimia haemolytica. Detection of Histophilus somni and Pasteurella multocida was associated with suppurative bronchopneumonia (SBP) and concurrent bronchopneumonia and bronchointerstitial pneumonia (BP&BIP), respectively. Sixteen viruses were identified, of which bovine parvovirus 2 (BPV2) was the most prevalent (11.5%, 15/130) followed by ungulate tetraparvovirus 1 (UTPV1, 8.5%, 11/130) and bovine respiratory syncytial virus (BRSV, 8.5%, 11/130). None of these viruses, however, were significantly associated with a particular type of pneumonia. Unconventional viruses such as influenza D virus (IDV) and bovine rhinitis B virus (BRBV) were detected, although sparsely, consistent with our previous findings in upper respiratory tract samples. Taken together, our results show that while virus detection in post‐mortem lung samples is of relatively little diagnostic value, the strong associations of H. somni and M. haemolytica with SBP and FBP, respectively, indicate that histopathology can be useful in differentiating bacterial aetiologies.