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Background There is uncertain evidence of effectiveness of 5-aminosalicylates (5- ASA) to induce and maintain response and remission of active Crohn's disease ( CD), and weak evidence to support their use in post-operative CD. Aim To assess the frequency and determinants of 5- ASA use in CD patients and to evaluate the physicians' perception of clinical response and side effects to 5- ASA. Methods Data from the Swiss Inflammatory Bowel Disease Cohort, which collects data since 2006 on a large sample of IBD patients, were analysed. Information from questionnaires regarding utilisation of treatments and perception of response to 5- ASA were evaluated. Logistic regression modelling was performed to identify factors associated with 5- ASA use. Results Of 1420 CD patients, 835 (59%) were ever treated with 5- ASA from diagnosis to latest follow-up. Disease duration >10 years and colonic location were both significantly associated with 5- ASA use. 5- ASA treatment was judged to be successful in 46% (378/825) of treatment episodes (physician global assessment). Side effects prompting stop of therapy were found in 12% (98/825) episodes in which 5- ASA had been stopped. Conclusions 5-Aminosalicylates were frequently prescribed in patients with Crohn's disease in the Swiss IBD cohort. This observation stands in contrast to the scientific evidence demonstrating a very limited role of 5- ASA compounds in the treatment of Crohn's disease. [ABSTRACT FROM AUTHOR]

Purpose: Spine surgery rates are increasing worldwide. Treatment failures are often attributed to poor patient selection and inappropriate treatment, but for many spinal disorders there is little consensus on the precise indications for surgery. With an aging population, more patients with lumbar degenerative spondylolisthesis (LDS) will present for surgery. The aim of this study was to develop criteria for the appropriateness of surgery in symptomatic LDS. Methods: A systematic review was carried out to summarize the current level of evidence for the treatment of LDS. Clinical scenarios were generated comprising combinations of signs and symptoms in LDS and other relevant variables. Based on the systematic review and their own clinical experience, twelve multidisciplinary international experts rated each scenario on a 9-point scale (1 highly inappropriate, 9 highly appropriate) with respect to performing decompression only, fusion, and instrumented fusion. Surgery for each theoretical scenario was classified as appropriate, inappropriate, or uncertain based on the median ratings and disagreement in the ratings. Results: 744 hypothetical scenarios were generated; overall, surgery (of some type) was rated appropriate in 27 %, uncertain in 41 % and inappropriate in 31 %. Frank panel disagreement was low (7 % scenarios). Face validity was shown by the logical relationship between each variable's subcategories and the appropriateness ratings, e.g., no/mild disability had a mean appropriateness rating of 2.3 ± 1.5, whereas the rating for moderate disability was 5.0 ± 1.6 and for severe disability, 6.6 ± 1.6. Similarly, the average rating for no/minimal neurological abnormality was 2.3 ± 1.5, increasing to 4.3 ± 2.4 for moderate and 5.9 ± 1.7 for severe abnormality. The three variables most likely ( p < 0.0001) to be components of scenarios rated 'appropriate' were: severe disability, no yellow flags, and severe neurological deficit. Conclusion: This is the first study to report criteria for determining candidacy for surgery in LDS developed by a multidisciplinary international panel using a validated method (RAM). The panel ratings followed logical clinical rationale, indicating good face validity. The work refines clinical classification and the phenotype of degenerative spondylolisthesis. The predictive validity of the criteria should be evaluated prospectively to examine whether patients treated 'appropriately' have better clinical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: This systematic review summarises the literature on patient selection, decision-making, effectiveness and outcomes in the surgical treatment of lumbar degenerative spondylolisthesis (LDS). Introduction: In daily practice, decision-making in the treatment of LDS is challenging. There is little consensus on either the precise indications or prognostic factors for any specific therapy (operative or non-operative). Methods: We searched for LDS trials published between 01.01.1990 and 16.11.2011 in Medline, Embase, Cochrane Library and Cinahl. Two independent reviewers selected studies according to the inclusion criteria. Data were then extracted by two of the authors. Quality assessment was performed using the Downs and Black list for the clinical trials/studies and AMSTAR for the reviews. Results: Data synthesis: 21 papers met the inclusion criteria (2 studies comprising both a RCT and a concurrent observational analysis, 1 RCT, 6 prospective studies, 8 retrospective studies, 3 reviews, 1 review guideline). The quality of the clinical studies was on average 'fair' [mean score 15.6 points (range 10-19) out of 24 points (Downs and Black)]. The quality of the reviews ranged from 1 to 7 out of 11 points with an average of 5 points (AMSTAR). The study outcomes could not be subject to meta-analysis due to heterogeneity of study design and variable measure used. Conclusions: Despite there being many articles describing and/or comparing different surgical options for LDS, there was insufficient evidence to draw conclusions concerning clear indications for specific types of surgical treatment, predictors of outcome or complication rates. There remains a need to establish a decision-making tool to facilitate daily clinical practice and to assure appropriate treatment for patients with LDS. [ABSTRACT FROM AUTHOR]

Aliment Pharmacol Ther 2010; 32: 1007-1016 Summary Background About 30-50% of patients with Crohn's disease (CD) develop fistulae, implying significant disease burden and complicated clinical management. Aim To assess appropriate use of therapy for fistulizing CD patients enrolled in the Swiss Inflammatory Bowel Disease Cohort using criteria developed by the European Panel on the Appropriateness of Crohn's disease Therapy. Methods Specific questionnaires were used to gather information on disease and its management. We assessed appropriateness of therapy at enrolment for adult CD patients with one or several fistulae. Results Two hundred and eighty-eight CD patients had fistulizing disease, of which 80% had complex fistulae and 32% currently had active draining fistulae. Mean age (s.d.) at diagnosis was 27 years (11), 51% males. Of the patients, 78% were judged as having globally an appropriate therapy, which was more often given for complex fistulae (87%) than for simple fistulae (67%). Antibiotics, azathioprine/MP, methotrexate and conservative surgery were almost always appropriate. Anti-tumor necrosis factor α was considered globally appropriate (91%), although most often with an uncertain indication. The 5ASA compounds, steroids and aggressive surgery were most often inappropriate (84%, 58% and 86% respectively). Conclusions Formal appropriateness criteria for CD therapy were applied to a national cohort of IBD patients. For more than three-quarters of the patients with fistulizing CD, therapy was globally appropriate. [ABSTRACT FROM AUTHOR]

Objective: To examine the appropriateness and necessity of colonoscopy across Europe.Design: Prospective observational study.Setting: A total of 21 gastrointestinal centers from 11 countries.Participants: Consecutive patients referred for colonoscopy at each center.Intervention: Appropriateness criteria developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy, using the RAND appropriateness method, were used to assess the appropriateness of colonoscopy.Main Outcome Measure: Appropriateness of colonoscopy.Results: A total of 5213 of 6004 (86.8%) patients who underwent diagnostic colonoscopy and had an appropriateness rating were included in this study. According to the criteria, 20, 26, 27, or 27% of colonoscopies were judged to be necessary, appropriate, uncertain, or inappropriate, respectively. Older patients and those with a major illness were more likely to have an appropriate or necessary indication for colonoscopy as compared to healthy patients or patients who were 45-54 years old. As compared to screening patients, patients who underwent colonoscopy for iron-deficiency anemia [OR: 30.84, 95% CI: 19.79-48.06] or change in bowel habits [OR: 3.69, 95% CI: 2.74-4.96] were more likely to have an appropriate or necessary indication, whereas patients who underwent colonoscopy for abdominal pain [OR: 0.64, 95% CI: 0.49-0.83] or chronic diarrhea [OR: 0.54, 95% CI: 0.40-0.75] were less likely to have an appropriate or necessary indication.Conclusions: This study identified significant proportions of inappropriate colonoscopies. Prospective use of the criteria by physicians referring for or performing colonoscopies may improve appropriateness and quality of care, especially in younger patients and in patients with nonspecific symptoms. [ABSTRACT FROM AUTHOR]

The use in Switzerland of three chest X-ray imaging modalities is studied. The frequency and dosimetric aspects associated with chest radiography, chest CT, and photofluorography are investigated and the Swiss figures are compared with those of other countries. The frequencies are established by means of a nationwide survey performed in 1998, whereas the doses are determined by modelling, based on the technical parameters of the examinations. The annual frequencies of chest radiography, chest CT, and photofluorography are 201, 7, and 7 per thousand population, respectively. The standard effective doses related to these three types of examinations are 0.057, 9, and 0.13 mSv, respectively. The collective dose associated with chest X-ray imaging amounts to 606 man.Sv, representing 8.5% of the total collective dose due to diagnostic and interventional radiology. The geographic and seasonal variations, as well as the distribution with the medical specialty and with the age of the patient, are established. The Swiss results compare well with the average data published in the literature for other countries of similar health care level. Chest radiography shows a significant decrease with time. It dropped by a factor of 2 in 20 years. The conformity of the indication of chest X-ray modalities with referral guidelines is also investigated. [ABSTRACT FROM AUTHOR]

Background: Variations in colonoscopy practice exist, which may be related to healthcare quality., Aims: To determine factors associated with three performance indicators of colonoscopy: complete colonoscopy, adenomatous polyp diagnosis, and duration., Patients: Consecutive patients referred for colonoscopy from 21 centres in 11 countries., Methods: This prospective observational study used multiple variable regression analyses to identify determinants of the quality indicators., Results: Six thousand and four patients were included in the study. Patients from private, open-access centres (odds ratio: 3.17, 95% confidence interval: 1.87-5.38) were more likely to have a complete colonoscopy than patients from public, gatekeeper centres. Patients from centres where over 50% of the endoscopists were of senior rank were roughly twice as likely to have an adenoma diagnosed, and longer average withdrawal duration (odds ratio: 1.08, 95% confidence interval: 1.07-1.09) was associated with more frequent adenoma diagnoses. Patients who had difficulty during colonoscopy had longer durations to caecum (time ratio: 2.87, 95% confidence interval: 2.72-3.01) and withdrawal durations (time ratio: 1.26, 95% confidence interval: 1.18-1.33) than patients who had no difficulties., Conclusions: Multiple factors have been identified as being associated with key quality indicators. The non-modifiable factors permit the identification of patients who may be at greater risk of not having quality colonoscopy, while changes to the modifiable factors may help improve the quality of colonoscopy.

The age of the patient is of prime importance when assessing the radiological risk to patients due to medical X-ray exposures and the total detriment to the population due to radiodiagnostics. In order to take into account the age-specific radiosensitivity, three age groups are considered: children, adults and the elderly. In this work, the relative number of examinations carried out on paediatric and geriatric patients is established, compared with adult patients, for radiodiagnostics as a whole, for dental and medical radiology, for 8 radiological modalities as well as for 40 types of X-ray examinations. The relative numbers of X-ray examinations are determined based on the corresponding age distributions of patients and that of the general population. Two broad groups of X-ray examinations may be defined. Group A comprises conventional radiography, fluoroscopy and computed tomography; for this group a paediatric patient undergoes half the number of examinations as that of an adult, and a geriatric patient undergoes 2.5 times more. Group B comprises angiography and interventional procedures; for this group a paediatric patient undergoes a one-fourth of the number of examinations carried out on an adult, and a geriatric patient undergoes five times more.

Purpose: This study analyzes CT examinations in Switzerland., Materials and Methods: Using different sources (administrative data on the equipment, a 1998 nationwide inquiry into practices, and data provided by the Swiss University Hospitals of Basel, Zurich, and Lausanne), we determined the frequency of CT examinations (hospitals and private radiologists) in 1998 according to different descriptive variables and studied the progression in CT use over time., Results: CT scanners increased by 7% between 1998 and 2004. The average annual number of CT examinations in 1998 was 46.3/1000 population, 3.4% of all radiological examinations in Switzerland in 1997-1998. The most frequent examination was CT of the skull (24%), while private radiology institutes perform more CTs of the spine. More CT examinations were performed for men than for women (sex ratio M/F=1.17). The average annual increase in CT in Swiss hospitals varied from 8% for Basel to 18% for Lausanne. Finally, the proportion of pediatric examinations was 5%; their numbers appear to be stabilizing., Conclusion: There is a significant increase in CT examinations. It is hoped that our study will heighten awareness among doctors of CT examinations in order to optimize their use.

Objectives: To measure the frequencies of dental radiological examinations in Switzerland and to determine the associated collective radiation doses., Methods: To evaluate the frequencies, a sample of 376 dental practitioners and other institutions performing dental radiology were requested to fill in questionnaires designed to measure, amongst others, frequencies of dental radiodiagnoses according to type of examination, patient age and gender, dental specialty and type of surgery. The associated collective radiation doses were determined by multiplying the relevant frequencies with dose estimates obtained from recent measurements and calculations., Results: The total number of dental examinations performed in Switzerland in 1998 was 4.1 million (581 per 1000 population). Periapical, bitewing and panoramic radiographs were the most frequent types of dental examinations. The collective dose associated with dental radiology was 71 person.Sv. This amounts to an annual average effective dose to the population of 10 muSv per caput, which is in agreement with the figures reported for countries of similar healthcare level. Various features such as the age distribution of the radiographed patients, the forms of collimators used, film consumption and the use of digital imaging systems are presented., Conclusions: Several recommendations for dose reduction are made. These include the re-evaluation of the patterns and justification for prescribing some particular types of dental examinations as well as the avoidance of unnecessary irradiation by the use of rectangular collimation and high sensitivity F-speed films.