Udder health concepts that comply with organic principles - how to reduce therapies?

Both the consumers and the legislators expect products from healthy organic livestock. Consequently, keeping farm animals healthy has the highest priority in veterinary work on organic farms. Different Swiss FiBL projects on bovine mastitis in recent years were aimed at health concepts that comply with organic livestock production principles. This paper summarises some of the work carried out

Organic conform udder health concepts. How to reduce therapies

Both consumers and governments expect quality products from healthy organic livestock. In consequence, keeping farm animals healthy has the highest priority in veterinary work on organic farms. Different Swiss FiBL projects in mastitis of the last years were aimed in health concepts conform to organic livestock principles. One project includes 20 Farms (with an average of 15 cows per farm) of a Swiss high mountain region. It puts emphasis on milking hygiene, milking technology, mastitis treatment during lactation (homeopathy versus antibiosis) and dry-off treatment (homeopathy versus placebo and partially additional antibiotic). The overall result was a reduction of cows with a somatic cell count higher than 150’000/ml based on milk recording dates between January and May from 35% in 1998 to 17% in 2000. During the project the average number of treated mastitis cases per farm decreased from 10 to 4. A second project considering farms in the north west of Switzerland was aimed at the implementation of an organically conform udder health concept putting emphasis on the reduction of the use of antibiotics. In order to achieve this, it was envisaged that factors contributing to mastitis will consistently be eliminated or at least reduced by implementation of herd health management and, in addition, by the establishment of complementary therapy and prophylaxis in udder health in co-operation with the veterinarian. On the 3 pilot farms a reduction in the use of antibiotics from 70 treatments per 100 cow and year in 2000 (previous the start of the project) to 2 treatments per 100 cow and year in 2002 (second project year) could be shown. Thereby, the udder health status of the herds remained stable with around 65% of cows with a somatic cell count lower than 100’000/ml. The objective of the current project is the enlargement and implementation of the previous concept into practice. A project team of 5 veterinarians and 2 agronomists will collect data of mastitis causing factors on 100 new farms per year in Switzerland: housing, feeding, human-cow interaction, milking technology, milking hygiene. These data will be connected to the mastitis status of the herd based on quarter milk samples and milk recording dates. During a period of at least 2, years these farms will be intensively advised by the project team and the practical veterinarian. Therapies will primarily be based on homeopathic remedies. The development of mastitis causing factors and the mastitis status of the farms is followed up at regular intervals to show possible correlations between (changing) factors and mastitis status. In addition, an Internet based network of health data should be implemented for providing information for farmers and veterinarians in herd health management

Pro-Q: Strategien zur Verbesserung der Eutergesundheit und Minimierung des Antibiotikaeinsatzes in schweizerischen Biomilchviehbetrieben

Data of mastitis causing factors will be collected on 100 new farms per year in Switzerland: housing, feeding, human-animal-interaction, milking technology, milking hygiene. These data will be connected to the mastitis status of the herd based on quarter milk samples and milk recording data. During a period of at least 2 years these farms will be intensively advised by the project team and their practical veterinarians. Therapies will primarily be based on homeopathic remedies. The development of mastitis causing factors and the mastitis status of the farms is followed up at regular intervals to show possible correlations between (changing) factors and mastitis status. In addition, a network of health data should be implemented for providing information for farmers and veterinarians in preventive herd health management. The aims of the project are reduction in the use of antibiotics in udder treatment, improvement of the udder health state of the herds and, as a consequence, improvement of milk quality

La santé des mamelles dans les fermes laitières

Dans un projet de recherche sur 100 exploitations laitières le FiBL a développé et mis au point - avec l'aide financière du fonds Coop Naturaplan - un procédé alternatif, éthique et écologique pour l'assainissement des mamelles. La fiche téchnique contient des recommandations d' assainissement par étape des mamelles chez la vache laitière et conforme aux directives bio. Les mesures pour maintenir la santé des mammelles sans antibiotiques à long terme sont également présentées

pro-Q: Förderung der Qualität biologisch erzeugter Milch in der Schweiz durch Prävention und Antibiotikaminimierung. Abschlussbericht Mai 2003 bis April 2006

Zusammenfassung Ziel des pro-Q-Projektes ist die flächendeckende Tiergesundheits- und Milchqualitätssicherung in der Biomilcherzeugung unter Bioverordnungs-konformen Bedingungen. Die Milch soll mit einem minimalen Einsatz chemischer Arzneimittel produziert werden. Dabei soll eine gute Eutergesundheit gewährleistet werden. Um diese Ziele zu erreichen, werden wichtige Negativfaktoren speziell für die Eutergesundheit im Betrieb definiert. Sanierungskonzepte werden mit der Landwirtin / dem Landwirt und dem Tierarzt / der Tierärztin erarbeitet. Zur Darstellung der aktuellen Eutergesundheit werden die Kühe und ihre Euter klinisch, die Milch zytobakteriologisch untersucht. Gemeinsam mit den Bestandesveterinären wird ein Therapiekonzept für erkrankte Kühe erstellt, welches auf vorwiegend homöopathischer Behandlung in Verbindung mit zusätzlichen Massnahmen (z.B. häufigerem Ausmelken) beruht. Wesentliches Ziel ist dabei, das Therapiesystem derart umzustellen, dass der Einsatz von Antibiotika weitgehend vermieden wird. Ein wesentlicher Teil des Projektes ist die stetige Analyse aller verfügbaren Daten mit darauf basierenden umfangreichen Informationen für Landwirt und Tierarzt. Die Ergebnisse der 78 mind. einjährig und 16 über zwei Jahre betreuten Betriebe sind sehr unterschiedlich und müssen im Kontext der betriebsindividuellen primären Sanierungsstrategien gesehen werden. Während die Eutergesundheit sowie die Milchleistung im ersten Jahr kaum Unterschiede zeigen, werden die Herden im Durchschnitt etwas älter, insbesondere diejenigen mit primär besserer Eutergesundheit. Nach zwei Jahren zeigen sich in Betrieben mit schlechterer Eutergesundheit deutliche Verbesserungen der Zellzahl, während die eutergesünderen Betriebe sich verschlechtern. Dies ist in erster Linie auf die Umstellung auf antibiotikafreie Therapie zurückzuführen, wobei der Trend zum 3. Jahr hin wieder rückläufig ist. Es konnten bereits im ersten Jahr 15 von 19 Betrieben mit S. aureus-Problematik teilsaniert werden, 5 Herden davon sind vollständig saniert. Ebenso erfolgreich gestaltet sich das Konzept in Betrieben mit gelbem Galt (Sc. agalactiae), die alle nach einem Jahr Galt-negativ waren. Die Zahl der antibiotischen Mastitisbehandlungen stieg insgesamt im ersten Projektjahr aus Sanierungsgründen, sank aber im zweiten deutlich unter das Niveau des Vorprojektjahres. Im zweiten Projektjahr werden 3 von 16 Herden antibiotikafrei geführt. Das pro-Q-Projekt zeigt anhand von 5 Beispielbetrieben, dass sich das Programm wirtschaftlich für die meisten Betriebe bezahlt macht. Insgesamt gesehen weisen die Daten zudem darauf hin, dass sich ein relevanter Erfolg bezüglich der verschiedenen Kernziele vermutlich ab dem dritten Jahr einstellen wird. Dies berücksichtigend stellt das Projekt einen Erfolg für die TeilnehmerInnen dar und kann über den Biolandbau hinaus empfohlen werden. Das homöopathische Therapieprinzip hat zu keinen gravierenden Einbrüchen in der Eutergesundheit geführt. Betriebe, deren Situation eine sofortige Umstellung auf das antibiotikafreie Therapiesystem gestattete, zeigten sehr positive Betreuungseffekte. Das Therapiesystem ist daher in den meisten Fällen als erfolgreiche Alternative zur Antibiose zu betrachten. Die Einführung des Konzeptes im Biolandbau soll beispielgebend für andere Produktionsausrichtungen (z.B. integrierte Produktion) sein, die durchaus auch an dem Programm teilnehmen können

Extent of primary breast cancer surgery: standards and individualized concepts

Surgery is still a main therapeutic option in breast cancer treatment. Nowadays, methods of resection and reconstruction vary according to different tumors and patients. This review presents and discusses standards of care and arising questions on how radical primary breast cancer surgery should be according to different clinical situations. In most early breast cancer patients, breast conservation is the method of choice. The discussion on resection margins is still controversial as different studies show conflicting results. Modified radical mastectomy is the standard in locally advanced breast cancer patients, although there are different promising approaches to spare skin or even the nipple-areola complex. A sentinel node biopsy is the standard of care in clinically node-negative invasive breast cancer patients, whereas the significance of axillary lymphonodectomy seems to be questioned through a number of different findings. Although there are interesting findings to modify surgical approaches in very young or elderly breast cancer patients, it will always be an individualized approach if we do not adhere to current guidelines. Up to date, there are no special surgical procedures in BRCA mutation carriers or patients of high-risk families

The impact of HER2 phenotype of circulating tumor cells in metastatic breast cancer: a retrospective study in 107 patients

Background: In metastatic breast cancer (MBC), antigen profiles of metastatic tissue and primary tumor differ in up to 20 % of patients. Reassessment of predictive markers, including human epidermal growth factor receptor 2 (HER2) expression, might help to optimize MBC treatment. While tissue sampling is invasive and often difficult to repeat, circulating tumor cell (CTC) analysis requires only a blood sample and might provide an easy-to-repeat, real-time “liquid biopsy” approach. The present retrospective study was conducted to compare HER2 expression in primary tumors, metastatic tissue, and circulating tumor cells (CTCs) from MBC patients and to analyze the potential impact of HER2 overexpression by CTCs on progression-free (PFS) and overall survival (OS) in MBC. Methods: CTC-positive (five or more CTCs/7.5 mL blood; CellSearch®, Janssen Diagnostics) MBC patients starting a new line of systemic treatment were eligible for the study. HER2 status of CTCs was determined by immunofluorescence (CellSearch®). HER2 status of primary (PRIM) and metastatic (MET) tumor tissue was determined by immunohistochemistry. Data were analyzed using descriptive statistics and Kaplan–Meier plots. Results: One hundred seven patients (median age (range) 57 (33–81) years) were included. 100/107 (93 %) patients were followed-up for a median [95 % confidence interval (CI)] of 28.5 [25.1–40.1] months. Of 37/107 (35 %) CTC-HER2-positive patients only 10 (27 %) were PRIM-HER2-positive. 6/46 (13 %) patients were MET-HER2-positive; only 2/10 (20 %) CTC-HER2-positive patients were MET-HER2-positive. Overall accuracy between CTC-HER2 expression and PRIM-HER2 and MET-HER2 status was 69 % and 74 %, respectively. Kaplan–Meier plots of PFS and OS by CTC-HER2 status revealed significantly longer median [95 % CI] PFS of CTC-HER2-positive versus CTC-HER2-negative patients (7.4 [4.7–13.7] versus 4.34 [3.5–5.9] months; p = 0.035). CTC-HER2-positive status showed no significant difference for OS (13.7 [7.7–30.0] versus 8.7 [5.9–15.3] months; p = 0.287). Conclusions: HER2 status can change during the course of breast cancer. CTC phenotyping may serve as an easy-to-perform “liquid biopsy” to reevaluate HER2 status and potentially guide treatment decisions. Further, prospective studies are needed

Pathologie der Mamillenregion: I. Morbus Paget der Mamille, Varianten und Differentialdiagnosen

Der klassische M. Paget der Mamille ist histologisch charakterisiert durch eine intraepidermale Tumorinfiltration, die von einem intraduktalen oder invasiven Mammakarzinom ausgeht, immunhistologisch durch eine regelhafte Überexpression von HER2 und klinisch durch ekzemartige Veränderungen von Mamille und Areola. Zu den Varianten mit davon abweichenden histologischen, immunhistologischen und klinischen Erscheinungsformen gehören der isolierte M. Paget der Mamille, der anaplastische M. Paget, der M. Paget mit Invasion und der pigmentierte M. Paget der Mamille. Differentialdiagnostisch ist der M. Paget der Mamille abzugrenzen gegenüber benignen Veränderungen, insbesondere der Tokerzellhyperplasie, dem Mamillenekzem und seltenen Dermatosen

Refining scores based on patient reported outcomes – statistical and medical perspectives

Background: Patient Reported Outcomes (PRO) are gaining more and more importance in the context of clinical trials. The assessment of PRO is frequently performed by questionnaires where the multiple items of a questionnaire are usually pooled within summarizing scores. These scores are used as variables to measure subjective aspects of treatments and diseases. In clinical research, the calculation of these scores is mostly kept very simple, e.g. by a simple summation of item values. In the medical literature, there is hardly any guidance for performing a refinements of questionnaires and for deducing adequate scores. In contrast, in psychometric literature, there are plenty of more sophisticated methods, which overcome typical assumptions made in traditional (sum) scores, however to the prize of more complicated algorithms, which might be difficult to communicate. When faced with the practical task to refine an existing questionnaire, there exist a clear gap of guidance for applied medical researchers. By this article we try to fill this important gap between psychometric theory and medical application by illustrating our methodological choices on the example of a clinical PRO questionnaire. Methods: Based on our experiences with the refinement of the BCTOS, a PRO questionnaire to assess aesthetic and function after breast conserving therapy in breast cancer patients, we present the following general steps that we performed by refining the BCTOS questionnaire and its scores: 1. Refinement of the length of the questionnaire and the (item-factor) structure. 2. Selection of the factor score estimation method. 3. Validation of the refined questionnaire and scores with respect to validity, reliability and structure based on a validation cohort. Results: Our step-step-step procedure helped us to shorten the current form of the BCTOS and to redefine the factor structure. By this, the compliance of patients can be increased and the interpretation of the results becomes more coherent. Conclusions: We present a step-by-step procedure to refine an existing medical questionnaire along with its scores illustrated and discussed by the refinement of the BCTOS. Trial registration: Due to the character of the study (no intervention study), no registration was performed

Imaging of lumpectomy surface with large field-of-view confocal laser scanning microscopy 'Histolog® scanner' for breast margin assessment in comparison with conventional specimen radiography

Purpose: The Histolog® Scanner (SamanTree Medical SA, Lausanne, Switzerland) is a large field-of-view confocal laser scanning microscope designed to allow intraoperative margin assessment by the production of histological images ready for assessment in the operating room. We evaluated the feasibility and the performance of the Histolog® Scanner (HS) to correctly identify infiltrated margins in clinical practice of lumpectomy specimens. It was extrapolated if the utilization of the HS has the potential to reduce infiltrated margins and therefore reduce re-operation rates in patients undergoing breast conserving surgery (BCS) due to a primarily diagnosed breast cancer including ductal carcinoma in situ. Methods: This is a single-center, prospective, non-interventional, diagnostic pilot study including 50 consecutive patients receiving BCS. The complete surface of the specimen was scanned using the HS intraoperatively. The surgery and the intraoperative margin assessment of the specimen was performed according to the clinical routine consisting of conventional specimen radiography as well as the clinical impression of the surgeon. Three surgeons and an experienced pathologist assessed the scans produced by the HS for cancer cells on the surface. The potential of the HS to correctly identify involved margins was compared to the results of the conventional specimen radiography alone as well as the clinical routine. The histopathological report served as the gold standard. Results: 50 specimens corresponding to 300 surfaces were scanned by the HS. The mean sensitivity of the surgeons to identify involved margins with the HS was 37.5% ± 5.6%, the specificity was 75.2% ± 13.0%. The assessment of resection margins by the pathologist resulted in a sensitivity of 37.5% and a specificity of 81.0%, while the local clinical routine resulted in a sensitivity of 37.5% and a specificity of 78.2%. Conclusion: Acquisition of high-resolution histological images using the HS was feasible in clinical practice. Sensitivity and specificity were comparable to clinical routine. With more specific training and experience on image interpretation and acquisition, the HS may have the potential to enable more accuracy in the margin assessment of BCS specimens