No, this is not a Mauke – or: what does all this have to do with lymph?
This blog post is about a new, very old disease. Does that sound strange? Well, then I hope I have your attention, because the following is about fascinating scientific findings, old myths and misinformation. And about many horses, whose suffering might be better understood now. Does that sound strange? Well, then hopefully I’ll get your attention, because the following is about fascinating scientific findings, old myths and misinformation. And to many horses whose sufferings may now be better understood.
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The topic is about a disease that has been described for a few years and was previously wrongly attributed to the Mauke under another name: the Warzenmauke. It got its name because of its appearance in the late stage: the furrows and thick lumps. There is plenty of information about Mauke on the Internet, e.g. here in the blog. The contributions almost always list different levels and forms of Mauke. Warzenmauke is often one of them. Depending on the source, it is named either as a strong form or late stage or as a special variant of the Mauke. The latter hits the heart, but it is also wrong. To preface: the term “Warzenmauke” should no longer be used. The short form: what the term wants to describe is definitely not a Mauke! The long form is the complete following text. It got its name because of its appearance in the late stage: the furrows and thick gags. There is plenty of information on the topic of Mauke on the Internet, e.g. here in the blog. The contributions almost always list different levels and forms of Mauke. Warzenmauke is often one of them. Depending on the source, it is named either as a strong form or late stage or as a special variant of the Mauke. The latter hits the heart, but it is also wrong. To preface: the term “Warzenmauke” should no longer be used. The short form: what the term wants to describe is definitely not a Mauke! The long form is the complete following text.
The disease was first described in more detail in 2003 and clearly distinguished from Mauke. The disease is chronic,i.e. there is no cure. The disease is chronic,i.e. there is no cure. It deteriorates without treatment, is therefore“progressive”and, according to current findings, affects the lymphatic system. There is edema-like thickening. This is how it got its name: Chronic Progressive Lymphoedema (CPL). It occurs across breeds, especially in cold-blooded animals at the lower extremities. Particularly affected are the Belgian Cold Blood (Brabanter), Tinker, Rheinisch-Deutsches Kaltblut, as well as Shire Horse and Clydesdale. In the meantime, a lot has been done in research on CPL regarding etiology (considering the causes of disease development) and diagnostics.
Still occurring false mentions
In English-language literature, besides the current term “Chronic progressive lymphedema”, the following older, but actually wrong, names for CPL can be found:
Chronic idiopathic pasters dermatitis, chronic pasters dermatitis, elephantiasis or equine lymphoedema complex (ELC)
In German-language literature, the following false terms for CPL are still encountered:
Chronische Mauke, verruköse Mauke, verruköse Pastern Dermatitis, Warzenmauke oder Warzenmauke-Syndrom
Description and characterization
CPL is a multifactorial disease. Similar to Mauke, many factors (such as posture, diet, race, etc.) meet in order to cause the disease. Affected horses are born healthy, but bring with them a certain genetic burden. They do not initially show any symptoms. The outbreak of the disease can occur from the age of one year. From then on, the CPL signs progressively get worse. They are typically localized on the lower legs: swelling and fibrosis of the soft tissue, associated with permanent deformations and skin abnormalities.
Veterinarians Toon van Couter, Jozef Colman and Cécile De Cupere described the different stages of the disease at a conference on the subject in Sint-Niklas, Belgium (organized by Trekpaard Jeugd VFBT) at the beginning of 2018 as follows:
- In the initial stage, only the skin in the bondage cavity is slightly thickened, possibly with a slight wrinkle, which is only visible after a shave.
- Gradually, the wrinkles become clearer and sometimes some cracks appear, causing the epidermis to become scaly and create small wounds or crusts. As lesions [damage, injury or disturbance of ananatomical structure or physiological function, note] develop, the skin slowly becomes thicker and harder. At first, the horse seems to be responding to all sorts of therapies, but the healing does not occur. At some point, the problem gets worse and worse. This is a clear difference from Mauke.
- The wrinkles become thicker and spread both forward and up on the leg. The small gaps develop into larger, bleeding wounds. In addition, secondary infections often occur, which aggravate the disease process. The skin between the wrinkles becomes moist and spreads a smell that attracts flies.
- In the advanced stage, the extremity is strongly thickened and the skin folds reach up to the knees. When you touch the legs, they feel hard. They usually develop large, hard lumps that can grow up to the size of a tennis ball. These lumps are a mechanical problem as they hinder the movement of the animal. This can easily injure them at work. The epidermis is now dry, swaying and shows a pronounced scale.
The obductions of deceased horses with CPL reveal characteristic signs of chronic lymphoedema: the dermis is strongly thickened. First by fluid accumulation, later more and more by deposition of collagen connective tissue. These are more pronounced locally in some places and visible as nodules. With the constant spread of the disease, thick-walled, enlarged and sinuous lymphatic vessels appear in the subcutaneous connective tissue.
In addition to its important role for the immune system, the lymphatic system has another crucial task: the removal of pollutants and large-molecular particles, such as proteins, cell debris or lymphocytes from the intercellular space. You can leave the interstitium (here: cell space) only through the lymphatic vessels. If the lymphatic system fails, these substances remain in the interstitium. Lymphoedema or fibrosis can form.
Wikipedia describes the lymphatic system as follows:
“As lymph (Latin lympha ‘clear water’; Plural lymphae; originally Roman freshwater deity) is the aqueous light yellow liquid contained in the lymphatic vessels, which forms the intermediate link between the tissue fluid (intercellular fluid) and the blood plasma. The lymphatic system with the lymphatic vessels as conductive pathways is the most important transport system in the human body, in addition to the bloodstream. It specializes in the transport of nutrients and waste materials and also disposes of pathogens such as bacteria and foreign bodies in the lymph nodes.”
By means of the imaging examination methods lymphangiography and lymphoszintigraphy, the following typical symptoms can be depicted in horses affected by CPL:
- At the level of the distal (in relation to body regions or limbs: further from the center of the body) limbs show significantly enlarged and distorted lymphatic pathways.
- A reduced outflow of lymph from the lower legs becomes visible.
- A generally reduced function of the lymphatic vessels is confirmed.
Elastin – cause or symptom?
It was found that a lower concentration of elastin is present in the skin of the affected horses before clinical lesions are visible. In the further course of the disease, further elastin fibers are deposited in the skin and try to repair the damage. However, this elastin is of poor quality and aggravates the situation. It spreads to the surrounding tissue and causes a thickening of the skin, skin wrinkles and all the above symptoms known in CPL.
Evil Friends – Mauke and CPL
The exact reasons for the malfunction are still unknown. Poorly functioning lymphatic system is one of the causes. In addition, there are other factors such as genetic predisposition, diet, exercise, posture and the environment. The latter factors may also lead to Mauke (link to Mauke article). Unfortunately, both diseases “complement” each other very well. Skin weakened by CPL is more easily prone to secondary infections, where a real mauke is quickly added. The extent to which a mauke that promotes genetically pre-stressed occurrence of CPL is not well studied, but obvious.
Pumps, pressures and running
In humans, the flow of lymph in the lymphatic system is made possible, among other things, by contractions called “lymphvascular muscle cells”, which contract (contract) rhythmically due to the filling stimulus within the lymphatic vessels. This function is called the “lymph vessel wall pump”. According to Prof. Dr. Dirk Berens von Rautenfeld (http://www.ml-pferd.de/), his research shows “that in the horse a different drive system for the lymph flow ratios in the form of numerous elastic fibers of about 40 of the vascular wall proportion is not only formed in the subfaciative collectors, which however only works in the moving horse. This elastic retraction pump is also significantly supported, especially in the case of horses, by the compressive effect of the particularly collagen-rich and elastic skin and the hoof and bond joint pump.” If the effect of the elastic retraction pump is missing due to the above-mentioned elastin disorders, the lymph cannot be sufficiently removed.
At the beginning of the 2000’s, the Hannover University of Animal Studies (TiHo Hannover) provided the first valuable findings in the context of dissertations. CPL has already been clearly differentiated by Mauke. Universities and colleges in the Benelux region are currently doing intensive research on the topic in an EU research project and receive good support from breeders and breeding associations of affected horse breeds. One of these breeds is the Belgian Cold Blood (Brabanter or “trekpaard”), which is particularly affected by CPL. For several years now, the breeding association has been supporting Belgian researchers, among others, in order to better understand and treat this disease. TiHo Hannover is currently researching PSSM and its genetic background.
The results of this research bring new insights into genetic relationships, but also methods that can be used by laypeople, e.g. the severity of a CPL disease. This uniform classification made it possible to sample and statistically evaluate hundreds of horses. During the promotion of Kirsten De Keyser (K.U. Leuven) in the years 2009 to 2011, a large number of Belgian cold-blooded horses (625 horses) were examined in official breeding shows and during stable visits on the basis of this evaluation scheme.
Since then, the CPL classification according to the above-mentioned scheme (AA to D) is an official part of a classification at the Belgian Cold Blood, or the Brabanter, and decides whether the affected horse is even shown in the arena for the run. The association is determined to correct the mistakes of the past regarding CPL.
At the moment it is assumed that the Belgian cold blood was unwittingly accepted by very tight line breeding and the desire for a lot of hanging. The shire horse and Clydesdale have similar experiences. In the past, a lot of hanging was placed there. In the meantime, the desire for hanging is still in their breeding guidelines, but this should be “fine and silky”. Thick and wavy hair on the hanging was considered an indicator of CPL (or was incorrectly assigned to the wart mauke). The relationship between hair thickness and CPL has now been scientifically well studied. The results refute the direct relationship between CPL and the thickness of the hair in the hanging.
The suspicion that the CPL is partially hereditifier has been confirmed by the research. The underlying genes that affect CPL are not yet known. Possible heritability should be sufficient reason to remove affected animals from breeding in order to eliminate the disease in the herd as far as possible.
Belgian cold-blooded stallion Oskar is believed to be one of the “founders” of CPL in his breed. The animal had both summer eczema and CPL. Many successful stallions, which were used for breeding in the Rhineland and in Westphalia, come from his lineage. Most of the stallions descended from Oskar were themselves severely ill with CPL [Schäper W, 1937, cit. Wallraf A 2003]
The breeding associations of the Belgian Cold Blood (Brabanter) are currently the most consistent way to enforce the CPL elimination. Stallions have to be re-approved there every year. The score of the leg status is added each time. Thus, a stallion, in which CPL occurs after the first certification, can still be taken out of breeding in time.
The two-tier edits of Shire Horse and Clydesdale aren’t quite as consistent as to detect CPL. Nevertheless, this is always better than one-off grains of other breeds in order to be able to take affected stallions out of breeding. At the age of two and five years, the stallions are evaluated by a basket of baskets. Only after a successful second grading, stallions are licensed for life. CPL is easy to diagnose at the second grading.
A CPL was found in almost 60 of the horses examined. In the age group “three-year-olds and older”, almost 86 of the horses examined are affected by CPL. According to the figures, stallions are much more affected than mares. In addition, they developed the symptoms faster with age. Some horses had mild symptoms from the age of one year (14 of the yearlings). Clear lesions usually occurred from the age of three.
These concrete figures show the state of the CPL in the Belgian Cold Blood. The results of the course of the disease can be transferred to Shire Horse and Clydesdale. In my subjective estimation, however, both breeds are not as strongly immeated with CPL.
The timing and severity of the phase in which treatment is started influences the final result. Note: “The early bird relieves CPL.”
The CPL is currently (still) incurable and there is no clear supportive treatment. The best possible care, aftercare and possibly medical treatment can slow down the disease process and heal the wounds.
Note: Some of the products listed on the following pages are only examples and do not constitute advertising or specific recommendations. Each horse can react differently to a product/drug. By using certain products, a horse may no longer be suitable for slaughter (for human consumption).
The legs must be kept clean. Washing and rinsing with running water or a water bath, ideally with nozzles, are helpful. Too frequent washing, especially with additives, is counterproductive and leads to a softening of the skin.
ACHTUNG: with too frequent washing, and thus permanently moist skin, you run the risk of getting maggots into the wounds especially in summer! This makes the situation worse and you deal with a lot of consequential diseases!
Reduction of hanging
The hanging of the legs should be kept short so that more air can reach the wounds and they dry faster. It facilitates further treatment and reduces skin scales, which can be used as food for mites. Complete shaving (except for the skin) is rather concomitant, the renewable stubble itchy and irritating. If the hair stays one or two centimeters, can be treated just as well.
Movement and activity
It is necessary and promotes blood circulation and the outflow of the lymph. Movement is generally required for the running animal horse. As already written above, the “elastic retraction pump” of the lymphatic vessels present in the horse requires sufficient movement by the horse. Lack of exercise and insufficient blood supply increase the risk of thick legs and muscle weakness.
Manual Lymph Drainage (MLD)
MLD is a special massage technique that acts directly on the lymphatic system to improve lymphatic runoff, activate the immune system and relieve pain. Note: A little further down is a very detailed description of the treatment method MLD.
Bandages and pressure bandages allow the muscles around the lymph to perform the massage themselves, so that the fluid is automatically moved during movement. Disadvantage: The heat generated among the bandages can lead to increased infections with mites and other microorganisms. More modern alternatives are (tailor-made) medical compression bandages made of an air- and moisture-permeable tissue, e.g. Equicrown compression bandages (www.equicrown.de).
Bandagier documents made of natural sheep wool contain a high proportion of lanolin (natural wool wax). It has a healing and antibacterial effect by nature, keeps the skin dry and is breathable. Information about the product and the application can be found, for example. at schneepferd.at.
General, health-promoting measures
In addition to classical medicine, there are positive testimonials for complementary applications in the field of homeopathy or naturopathy. I have received reports that, for example, acupuncture can support the lymphatic system. And everything that is good for the lymph supports.
Good barn and pasture hygiene is important to keep the living environment healthy. A moist barn and/or a wet pasture are counterproductive, the skin becomes more sensitive. Sufficient exercise and possibly additional stimulation of the lymphatic system are important factors.
Care and accessories
Disinfection is crucial. For example, salt, chlorine or other disinfectants can be added to the water used to flush the legs. Salt baths are currently the means of choice. The natural variant: wade and ride in the sea! The technical luxury alternative was presented at Equitana 2018. In Belgium, flat bathtubs are common, in which you can place the horse. Slightly more mobile and easier to handle are small tubs for one or two legs. which can be combined, for example, with a fitting level. 20 minutes per leg in the water bath is enough, no hours of soaking.
Beauty tip: Holiday with the horse by the sea and ride generously in the knee-deep water. This cleanses fur and skin, has an antibacterial effect and strengthens the soul of the horse and rider. In Holland and Belgium there are regular processions at the start of the season, which solemnly decorate their horses into the sea water. Helps also with “normal” Mauke.
Betadine as shampoo or as an exfoliation (product with highly disinfecting properties, also for hairy skin, iodine-based) is recommended for disinfection of severe wounds. However, it should not be used too often to avoid unnecessarily softening the skin.
Tea tree oil shampoo is a good-acting agent with a cooling and itching-relieving effect on the skin.
Nutrition and supplementary feed
Support via feeding is possible from “inside”. In parallel with a basically horse-friendly diet, which takes into account not only the breed of the horses, but also their work needs, herbs and feed supplements can help. E.g. supports Galium aparine (Kletten-Labkraut) the lymph nodes. Turmeric – in combination with black pepper – relieves digestion, as well as joints and muscles. Nettle promotes the removal of waste materials.
There is a wide selection of ointments and creams to treat wounds. What works for one horse can have a lesser impact on another horse. Experience has shown that tea tree oil, (manuka) honey ointment, green clay, healing earth (e.g. from Luvos or Bullrich), udder cream, zinc ointment, betadin gel, or sulfur flower work with oil. Experience in mauke treatment helps here, where damaged skin must also be supported.
In case of severe wounds, medical advice is required! Each horse can react differently to a product. Always ask your veterinarian!
Subject to great reservation, only after consultation with the veterinarian and only if it is no longer possible: Sarnacuran or Sebacil is used against predatory mites (Psoroptes, Sarcoptes, Chorioptes), biting and sucking lice, Trichodectes, sheep’s louse fly, ticks, flies and larvae of flies (Kutane Myiasis, Flymade disease). It is dissolved in water according to the dosage instructions and applied. These means are quite aggressive and can do more harm than good when in doubt. Therefore, it is essential to weigh up the use and choose alternative treatment methods.
The best method for treating CPL is a combination of the above treatments. And it is important to start at an early stage of the disease.
Check your horse’s legs regularly to begin treatment for the first symptoms of CPL. Each treatment can significantly improve the quality of life.
Manual lymph drainage (MLD)
The following text (and the pictures) I took over from the lectures of the CPL-meeting of the breeding association of the Belgian Trekpaard and translated from dutch. The meeting took place in early 2018 in Sint-Niklaas, Belgium. Inevitably, there will be repetitions of statements from the above text. In order to be comprehensible and to maintain legibility, I have not changed the relevant passages. The copyright lies with Ine Swinnen and the trek pair Jeugd VFBT.
Ines Swinnen deals with the “manual lymph drainage”. This treatment method has been known in humans for a long time and is increasingly used in horses. She works as an independent MLD therapist at level 3.
The horse’s lymphatic system and its support by MLD
For many, the MLD is still unknown terrain for horses. Of the lymphatic system in general, laymen have certainly heard or known people who have removed lymph nodes. In addition, every horse owner knows the phenomenon of “stable legs”, horses with swollen jaws or even in cold blood horses the CPL. All these things have to do with the functioning of the lymphatic system.
What is the lymphatic system?
One must see the lymphatic system as an open network of vessels scattered throughout the body. It ensures that the liquid is discharged along with all kinds of waste and invaders such as bacteria. The lymphatic system begins very superficially, directly under the skin. and spreads deep around all organs. Through the suction effect of the system, the fluid is collected and directed to the lymph nodes. In these intermediate stations, the fluid is filtered and processes take place that support the immune system. With the help of lymphocytes, bacteria and viruses in the lymph nodes are also rendered harmless. After filtering, the harmless liquid is fed into the bloodstream for final disposal (via stool and urine).
There are a number of major differences between the blood vessel system and the lymphatic system. The circulatory system is a closed system in which the heart is the motor that pumps the blood through the body at a certain speed. As already mentioned, the lymphatic system, on the other hand, is an open network. It starts blindly in the tissue, where it can absorb the fluid pumped out by pressure differences in the circulatory system. It does not have an engine like the heart, but runs between the muscles and uses the pressure differences that arise there to push the lymphatic system forward.
In the lymphatic vessels there are valves, which ensure that the lymph flow occurs basically in one direction. This prevents the waste from flowing back into the organs. At a constant pressure on the lymphatic system, the collectors and thus the valves can be damaged, causing the liquid to stagnate and thus come to a standstill. The defined pressure (the “heartbeat”) present in the blood vessel system is not present in the lymphatic system. The lymphatic system reacts to pressure differences and works many times slower than the blood vessel system.
We humans have just over 400 lymph nodes. Horses have about 8000! These are mainly located deep around the organs. But there are also a few that can be approached superficially. The special thing about the lymph nodes is that half of the nodes of a horse are located around the stomach and intestines. These have an optimal function when a horse can eat all day long, as they need the peristaltic movement in the digestive system to do their job.
What does the lymphatic system do?
This all sounds complicated, but in short, the lymphatic system ensures that all waste materials that do not belong in the body are removed, leaving room for the supply of the necessary nutrients. This process forms the basis of a good recovery from trauma. Because it plays an important role in the body’s immune response, a well-functioning lymphatic system provides better overall resilience.
When we apply this to the CPL, we can see that problems with the legs are almost always the result of “trauma”. This can be a needle-stick-sized wound that you can’t even see with the naked eye, or a more serious problem. As a result of this trauma, tissue damage in the skin occurs. If the lymphatic system works properly, the invaders penetrated by a wound are rendered harmless and removed together with the damaged tissue pieces. In this way, space is created in the tissue to transport new building materials through the bloodstream and to start recovery.
If not enough nutrients get into the tissue, the body looks for another solution to enable recovery. However, this will be rather half-hearted. In such a situation, the body sets priorities: a blood vessel is always repaired in front of a lymphatic vessel. It is functionally more vital. What remains in this deficiency situation of building materials is introduced into the lymphatic vessels. This is often not enough to make the lymphatic vessels work sensibly. The result is that more fluid remains in the legs and connective tissue remains instead of properly repaired tissue. In the case of another trauma, this process will be further intensified. Finally, it can happen that the leg of a horse is full of connective tissue, in which hardly any effective lymph avessels are present. [The genetic predisposition of elastin weakness described above fuels this vicious circle. Note]
As mentioned above, the lymphatic system reacts to pressure changes normally caused by muscle contraction and relaxation in a body. That is why movement is such an important factor for the proper functioning of the lymphatic system. It does not work well when constant pressure is exerted from the outside. This pressure can be physical, but also mental. A horse that is given little time to “get the button free” from time to time and to relax completely can develop problems more quickly. This is especially true in sports horses today. But other horses can also experience pressure without the owner’s intention.
What makes the lymph happy?
Now that you have some understanding of how the lymphatic system works, you will soon find that we, as horse owners, regularly perform some unpleasant actions for the system. If you observe this, you can take a lot of things into account to support your horse optimally. Here are some practical examples that can negatively affect the dewatering of the lymphatic system and what you can possibly change. Simple example: stable management. Horses, which are often in the stable, “lock” the lymphatic system, so that firm legs are a well-known phenomenon. A lot of relaxed movement in the paddock or on the lawn can change that.
One of the activators of the lymphatic system is the hoof mechanism. A good hoof care should therefore not be lost sight of, because the hoof mechanism is located at the base of the pumping system in the legs. It is severely restricted by the irons. Ceilings and bridles are often in places that are very important for the lymphatic system. Because it’s so close to the surface, it’s relevant to check if your stuff always fits well. Many horses have to deal with a lot of physical and mental pressure. Just think of training, long-term transports, competitions, etc. These are situations where stress sometimes prevails and where good stress management can provide a solution. After the training, it can be a good way to ride your horse relaxed to relieve the tensions built up during the training. A common walk in the woods can sometimes be reassuring for both sides. In this way, stress can relieve itself and not accumulate in the body. This would be counterproductive for health – for humans and animals.
Ice-cold water is often used to rinse the legs after riding. Although opinion is divided on this issue, we can generally say that using slightly less cold water feels more pleasant. As a result, the lymphatic vessels are not completely compressed and their transport is not completely “on ice”.
Bandages are still an everyday object in the horse world. Unfortunately, these ensure that the superficial lymphatic vascular system in the legs is restricted in its function and can even be clamped. In the legs, the transport must be carried out against gravity, which in itself requires a great effort for the body. The valves of the system work only in one direction, so that a misdesigned bandage can damage it.
The pressure must always be applied from the bottom up. If your horse needs temporary support during transport or during a stable period, there are compression products that can make a big difference when used quickly.
What can be done if all the simple measures do not work?
Manual lymphatic drainage is a massage technique in which the lymphatic system is stimulated from the outside by applying the pressure change to the superficial system and some deeper lymph nodes in a relaxed manner. Since all lymphatic pathways are connected to each other, the superficially generated suction effect can alter deeper structures. The entire lymph must be removed at the front at the level of the heart, so it is understandable that many problems with the hind legs take a long time to recover. This lymph must go a longer way.
MLD therapists can support their treatment by using lymphatic band and compression stockings. These are also used in human medicine. Adapted stockings have been developed for horses. They support the body in its lymphatic function and can provide a solution for defined periods of time, so that the therapist’s work lasts longer. It must be borne in mind that the lymphatic system must be treated very specifically, an incorrect direction or stimulation can cause damage! Therefore, it is always important to contact a well-trained therapist. There are situations where manual lymphatic drainage is not the best (or first) choice, just like compression. These can sometimes only be used at a later stage of treatment.
MLD for CPL
Although CPL is a chronic disease in which heredity plays a role, MLD can be a very good addition to the management of a horse with CPL. It has a supportive effect on general resilience and promotes wound healing. In addition, it affects the mental health of your horse, so that the animal learns to relax better and relieve tension in its body itself. When the lymphatic system works optimally, the horse recovers faster and better from trauma and becomes less prone to injury as its transport capacity is greater. In the case of a small wound, the body can then solve everything itself, eliminating secondary infections. Manual lymphatic drainage treatment allows the horse to clean salye through its natural system and increase its recovery and regeneration.
Horses with CPL already have a harder time in terms of transport capacity. Therefore, it is certainly advisable to have the MLD performed by an experienced therapist. The sooner you start supporting the lymphatic system, the better it can continue to work. Undoing damage is much harder than preventing it. But: MLD should not be understood as the sole therapy of CPL.
Therefore, when treating horses with CPL, the positive and less positive parts of the horse’s environment are always taken into account and improvements are made where possible in consultation with the owner.
Link to scientific publications
Further links and current scientific publications can be found in the well-rounded overview of this Swiss page.