Gesundheit und Leistungsfähigkeit von Milchkühen im ökologischen Landbau interdisziplinär betrachtet – eine (Interventions-) Studie zu Stoffwechselstörungen und Eutererkrankungen unter Berücksichtigung von Grundfuttererzeugung, Fütterungsmanagement und Tierhaltung

Im Mittelpunkt des Projektes stand die Stoffwechsel- und Eutergesundheit von ökologisch gehaltenen Milchkühen im prä- und peripartalen Zeitraum sowie in den ersten 100 Laktationstagen und deren Beeinflussung durch die Futter- und Nährstoffversorgung und die Haltungsumwelt im umfassenden Sinn. In einer bundesweiten Feldstudie auf 106 ökologisch wirtschaftenden Milchviehbetrieben erfolgten Erhebungen mit dem Ziel einer Risikomodellierung zu Stoffwechsel- und Eutererkrankungen. Vor diesem Hintergrund wurden die Produktionssysteme von der Pflanzenzusammensetzung im Grünland und im Ackerfutter über die Grobfutterproduktion, Futterqualität und Rationsgestaltung, Haltungsumwelt bis hin zur Tiergesundheit und Milchqualität analysiert, um hier einzelbetriebliche Risikoeinschätzungen vorzunehmen, Optimierungspotenziale aufzuzeigen und Handlungsempfehlungen abzuleiten, die anschließend betriebsindividuell implementiert wurden. Die Effektivität des so geschaffenen präventiv orientierten Tiergesundheitsmanagements wurde anhand der Entwicklung ausgewählter Kennzahlen der Euter- und Stoffwechselgesundheit geprüft. Es konnte gezeigt werden, dass sich mit dieser Vorgehensweise auch unter Praxisbedingungen die Tiergesundheitssituation signifikant verbes-sern lässt. Die Feldstudie wurde mit experimentellen Untersuchungen ergänzt, die sich speziellen Fragen der Analyse von nXP in Grasprodukten, des Kraftfuttereinsatzes, der Wahl der geeigneten Rasse, dem Infektionsgeschehen, der Nutzung von Haltungstechniken im Fütterungsmanagement und der Verbesserung der Grasnarbe widmeten. Die im Projekt generierten, aufgrund ihrer Ableitung aus der Praxis widerspruchsarmen Erkenntnisse wurden über vielfältige Formen des Wissenstransfers an die Akteure in der Ökologischen Milchviehhaltung vermittelt. Ein Merkblatt zur Euter- und Stoffwechselgesundheit bei Biomilchkühen und ein modular aufgebautes Wissenstransferkonzept wurden erarbeitet, um die Projektergebnisse nachhaltig nutzen zu können

Analysis of Outcomes Associated With Outpatient Management of Nonoperatively Treated Patients With Appendicitis.

Importance: In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs. Objective: To assess the use and safety of outpatient management of acute appendicitis. Design, Setting, and Participants: This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020. Exposures: Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively. Main Outcomes and Measures: Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared. Results: Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores. Conclusions and Relevance: These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785

Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis

ObjectiveTo compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days.Summary background dataThe Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes.MethodsWe focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations.ResultsThe pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret.ConclusionsOverall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals.Trial registrationClinicaltrials.gov Identifier: NCT02800785