Use of a stochastic simulation model to estimate the cost per case of digital dermatitis, sole ulcer, and white line disease by parity group and incidence timing.

A farm-level stochastic simulation model was modified to estimate the cost per case of 3 foot disorders (digital dermatitis, sole ulcer, and white line disease) by parity group and incidence timing. Disorder expenditures considered within the model included therapeutics, outside labor, and on-farm labor. Disorder losses considered within the model included discarded milk, reduced milk production, extended days open, an increased risk of culling, an increased risk of death (natural or euthanized), and disease recurrence. All estimates of expenditures and losses were defined using data from previously published research in stochastic distributions. Stochastic simulation was used to account for variation within the farm model; 1,000 iterations were run. Sensitivity of foot disorder costs to selected market prices (milk price, feed price, replacement heifer price, and slaughter price) and herd-specific performance variables (pregnancy rate) were analyzed. Using our model assumptions, the cost per disorder case over all combinations of parity group and incidence timing, regardless of incidence likelihood, was lowest for digital dermatitis ($64 ± 24; mean ± standard deviation), followed by white line disease ($152 ± 26) and sole ulcer ($178 ± 29). Disorder costs were greater in multiparous versus primiparous cows and were always highest at the beginning of lactation. The greatest contributing cost categories were decreased milk production, an increased risk of culling, and disease recurrence. The contribution of cost categories to the total cost of disorder varied by disorder type, parity group, and incidence timing. For all disorders, the cost per case increased as milk price or replacement heifer price increased and decreased as feed price, pregnancy rate, or slaughter price increased. Understanding how foot disorder costs change according to cow-specific conditions (i.e., disorder type, parity group, and days in milk at incidence) and herd-specific conditions (i.e., market prices and performance variables) can help improve on-farm decisions about treatment and prevention of foot disorders.

Estimating the value of infectious or noninfectious foot disorder prevention strategies within dairy farms, as influenced by foot disorder incidence rates and prevention effectiveness.

A farm-level stochastic simulation model was adapted to estimate the value of implementing foot disorder prevention on a dairy farm by calculating the return on investment associated with implementation of foot disorder prevention. Two potential strategies for foot disorder prevention were tested: strategy 1 was prevention focused on reducing infectious foot disorders (i.e., digital dermatitis) in the model, and strategy 2 was prevention focused on reducing noninfectious foot disorders (i.e., sole ulcer and white line disease) in the model. For each strategy, we evaluated the effect of foot disorder incidence on the value of prevention by setting the incidence of foot disorders at 3 levels. For strategy 1, the level of digital dermatitis incidence without prevention in all parities was 20, 40, or 60%, and the incidence level of the noninfectious foot disorders in the model were held constant. For strategy 2, levels of sole ulcer and white line disease incidence without prevention in parity ≥3 cows were 5, 15, or 25%, and the incidence level of the infectious foot disorders included in the model were held constant; the incidence levels of noninfectious foot disorders in younger cows were adjusted to be lower. Overall, 6 scenarios were run, 1 for each prevention strategy × foot disorder incidence rate combination. To evaluate how the effectiveness of each prevention strategy would influence the investment value, the effectiveness of prevention could vary from a prevention risk ratio (RR) of 0.0 (100% reduction in disorder incidence) to 1.0 (0% reduction in disorder incidence). When implementing strategy 1, the return on prevention investment per cow-year (mean ± standard deviation) when prevention effectiveness was low (prevention RR = 0.91 to 1.0) and the digital dermatitis incidence rate was originally 20, 40, or 60% was $0.6 ± 0.4, $1.2 ± 0.9, and $1.8 ± 1.3, respectively. In comparison, the return on prevention investment per cow-year when prevention effectiveness was high (prevention RR = 0.00 to 0.09) and the digital dermatitis incidence rate was originally 20, 40, or 60% was $12.2 ± 3.0, $24.4 ± 6.0, and $36.5 ± 9.0, respectively. When implementing strategy 2, the return on prevention investment per cow-year when prevention effectiveness was low and noninfectious foot disorder incidence rates were originally 5, 15, or 25% in parity ≥3 cows was $0.6 ± 0.4, $1.9 ± 1.1, and $3.2 ± 1.9, respectively. In comparison, the return on prevention investment per cow-year when prevention effectiveness was high and noninfectious foot disorder incidence rates were originally 5, 15, or 25% in parity ≥3 cows was $12.4 ± 1.5, $37.3 ± 4.6, and $62.2 ± 7.6, respectively. The return on investment for foot disorder prevention would depend on the cost of the prevention strategy and the other benefits associated with the selected prevention strategy. This model could be used as a decision support tool to help identify the amount that could be paid to implement a selected prevention strategy.

Quality of Life in Depressed Patients in UK Primary Care: The FINDER Study.

OBJECTIVES: To investigate the impact of depression and its treatment on health-related quality of life (HRQoL) in a naturalistic, primary care setting in the UK. METHODS: The Factors Influencing Depression Endpoints Research (FINDER) study was a European, 6-month, prospective, observational study designed to estimate HRQoL in patients with a clinical diagnosis of depression. This paper examines primary care patients recruited in the UK. HRQoL was measured at baseline and at 3 and 6 months after starting antidepressant therapy using the Short Form 36 Health Status Survey and the European Quality of Life-5 Dimensions (EQ-5D). Regression analysis was used to identify baseline and treatment variables independently and significantly associated with HRQoL. Further analyses included the effect of caseness for depression on HRQoL, the effect of moderate/severe pain at baseline on HRQoL, changes in overall pain, pain interference scores, and the use of different antidepressants by pain cohort. RESULTS: A total of 608 patients was recruited from 58 centres and mean HRQoL was significantly below reported population norms at baseline. Most improvement in HRQoL was seen at 3 months for EQ-5D, with small additional improvement at 6 months. Worse HRQoL outcomes at 6 months were associated with higher somatic symptoms score, duration of depression at baseline, and switching within antidepressant classes. Patients meeting the criteria for caseness for depression, or with significant pain at baseline showed less improvement in HRQoL scores at 6 months. CONCLUSION: Patients presenting with depression in primary care show reduced HRQoL compared to population norms. HRQoL improves during antidepressant treatment particularly within the first 3 months. Nonpainful somatic symptoms, socioeconomic factors, depression variables and switching within antidepressant class predict poor HRQoL outcome. Pain is a common symptom in depressed patients and remains after 6 months' treatment. Pain and somatic symptoms should be assessed in all patients with depression in primary care.

Simplified technique to reduce perioral edema in intraoral sagittal split osteotomies.

A simplified technique has been developed for the prevention of the severe perioral edema that is routinely associated with intraoral sagittal split osteotomies of the ascending ramus of the mandible. By the use of gauze sutured through the cheeks in the region of the oral commissures, trauma caused by retraction of instruments is significantly diminished.