Original article 200Introduction ! Cancer of the colon and rectum (colorectal cancer [CRC]) is one of the most common cancers diagnosed in Western countries and is a major cause of cancer-associated morbidity and mortality [1,2]. In Europe, the annual age-standardized incidence of CRC is 35 and 55 per 100 000 in women and in men respectively [1]. The age distribution of CRC shows a predominance in patients > 50 years with less than 10 % of patients being younger than 50 years [3]. The mean age at diagnosis was found to range from 65 to 71.5 years [4]. CRC is the second major cause of cancer mortality in both women and men. While the survival rate for early-stage cancers is high, the survival rate for those diagnosed with widespread cancer is low. About 75 % of all new cases of CRC occur in asymptomatic individuals with no known predisposing factor for the disease except age (≥ 50 years old; average risk) [5]. The remaining cases occur in individuals with a family history of CRC or adenomatous polyps, or with a family history of hereditary nonpolyposis colorectal cancer (HNPCC), or with familial adenomatous polyposis (FAP) or attenuated FAP. Screening, which refers to the search for colorectal lesions in asymptomatic patients with no personal history of CRC or adenomas, appears to be the best option available to reduce CRC morbidity and mortality by early detection of CRC in individuals ≥ 50 years old. However, there is debate about the best screening method and about whether colonoscopy should be recommended for CRC screening. In April 2008, a multidisciplinary European expert panel was convened in Montreux, Switzerland, to discuss and develop criteria for the appropriate use of colonoscopy. This article presents the literature review on screening for CRC in asymptomatic individuals that was provided to Background and study aims: To summarize the published literature on assessment of appropriateness of colonoscopy for screening for colorectal cancer (CRC) in asymptomatic individuals without personal history of CRC or polyps, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, systematic reviews, and primary studies regarding colonoscopy for screening for colorectal cancer was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy in these circumstances. Results: Available evidence for CRC screening comes from small case-controlled studies, with heterogeneous results, and from indirect evidence from randomized controlled trials (RCTs) on fecal occult blood test (FOBT) screening and studies on flexible sigmoidoscopy screening. Most guidelines recommend screening colonos-

No abstract

Original article 209Introduction ! Cancer of the colon and rectum (colorectal cancer [CRC]) is one of the most common cancers diagnosed in Western countries and the second most common cause of cancer deaths [1,2]. It is generally accepted that most CRCs develop through a continuous process from normal mucosa to benign adenoma and then to carcinoma [3 -5]. While nearly all CRCs arise from adenomas, only a small minority of adenomas progress to cancer. Adenomas with advanced features, i. e. > 1 cm in diameter, with high-grade dysplasia, with > 25 % villous histology, or with invasive cancer, have the highest potential for malignancy. The removal of adenomas, by endoscopic polypectomy or surgical resection, is thus recommended to prevent CRC. After polypectomy, individuals are placed under colonoscopic surveillance to reduce the risk of development of and death from CRC, by detection and removal of new adenomas at surveillance colonoscopy. However, the overall prevalence of adenomas in the population is high (̃30 % at age 50 and̃50 % at age 70) and a large number of patients with adenomas are now being identified as a result of the increased use of CRC screening, particularly the dramatic increase in screening colonoscopy, thus placing a huge burden on medical resources applied to surveillance. There is a need for increased efficiency of surveillance colonoscopy practice, to decrease the cost, risk, and overuse of resources for inappropriate examinations. After diagnosis of CRC, between 66 % and 85 % of cancers can be surgically resected with curative intent [6 -8]. After CRC resection, patients are Background and study aims: To summarize the published literature on assessment of appropriateness of colonoscopy for surveillance after polypectomy and after curative-intent resection of colorectal cancer (CRC), and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of surveillance colonoscopy after polypectomy and after resection of CRC was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. Results: Most CRCs arise from adenomatous polyps. The characteristics of removed polyps, especially the distinction between low-risk adenomas (1 or 2, small [< 1 cm], tubular, no highgrade dysplasia) vs. high-risk adenomas (large [≥ 1 cm], multiple [> 3], high-grade dysplasia or villous features), have an impact on advanced

No abstract

Iron-deficiency anemia (IDA) is a condition where objective iron deficiency is at the origin of the anemia. The World Health Organization (WHO) defines anemia as a hemoglobin value of < 120 g/l for nonpregnant women, and < 130 g/l for men. IDA is a very common condition, particularly in women. In industrialized countries, it is estimated that 23 % of pregnant women, 10 % of all women (15 -59 years), 4 % of men (15 -59 years) and 12 % of elderly individuals ≥ 60 years are anemic [1]. IDA is commonly (62 %) caused by chronic blood loss from the gastrointestinal tract. Peptic ulcerations are the commonest lesions found in the upper gastrointestinal tract, while cancers are one of the most common abnormalities discovered in the colon. Other causes of IDA include cumulative menstrual blood loss or pregnancy in premenopausal women, decreased gastrointestinal absorption (malabsorption syndromes), and chronic intravascular hemolysis, among others. Lower gastrointestinal bleeding (LGIB) usually refers to blood loss originating from a lesion distal to the ligament of Treitz [2], even though approximately 10 % of patients with hematochezia may have an upper gastrointestinal source of bleeding [3,4]. LGIB may manifest itself as hematochezia (rectal bleeding: visible bright red or maroon blood per rectum), as opposed to melena (dark stools), which is most often a manifestation of upper gastrointestinal bleeding. Acute LGIB is of recent duration (< 3 days) and may result in hemodynamic instability, rapid hemoglobin decrease and/or the need for blood transfusion [5]. Chronic LGIB corresponds to the passage of blood per rectum over > 3 days. The patient with chronic bleeding may present with fecal occult blood (IDA and/or positive fecal occult blood test Background and study aims: To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of iron-deficiency anemia (IDA) and hematochezia, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of IDA and hematochezia was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. Results: IDA occurs in 2 % -5 % of adult men and postmenopausal women. Examination of both the upper and lower gastrointestinal tract is recommended in patients with iron deficiency. Colonoscopy for IDA yields one colorectal cancer (CRC) in every 9 -13 colonoscopies. Hematoche-

No abstract

ObjectivesTo assess the maturity of the Swiss healthcare system for integrated care and to explore whether this maturity varied according to several variables.DesignA Swiss nationwide individual electronic survey in November 2019.Setting and populationStakeholders identified via lists of the Swiss Forum for Integrated Care and of the integrated care unit of the Swiss Federal Office of Public Health, and representatives of 26 cantonal public health departments, were invited to participate.Primary outcome measureThe outcome was the maturity of the Swiss healthcare system for integrated care, measured with the Scaling Integrated Care in Context maturity model tool (SCIROCCO tool), which comprises 12 dimensions and questions rated on a 6-point scale.AnalysisUnivariate analyses were first performed, followed by bivariate analyses, to find out whether maturity varied according to working linguistic region, healthcare profession, main domain of professional activity, implication in integrated care, attitude towards integrated care and attitude towards the Swiss healthcare system.ResultsThe 642 respondents were 53.7 years on average, 42.5% were women, 60.0% and 20.7% worked in the German and French-speaking parts of Switzerland, respectively. Overall, the maturity of the Swiss healthcare system for integrated care was evaluated as low, with dimension means ranging from 1.0 (±1.0) for the ‘Funding’ dimension to a maximum of 2.7 (±1.1) for ‘eHealth Services’. Results only varied according to the working linguistic region.ConclusionsResults highlight a limited maturity of the Swiss healthcare system for integrated care, as assessed at a national level by a large and varied number of healthcare stakeholders. They represent important information for the further development of integrated care in Switzerland, and should help identify areas requiring attention for a successful transformation of the Swiss healthcare system towards more integrated care.

Chronic diarrhea is defined by a duration of > 4 weeks and > 3 loose stools/day [1]. Chronic diarrhea can have organic as well as functional causes. The most frequent organic origins identified in these patients include inflammatory bowel disease (IBD) (7 % -14 %), infectious causes (11 % -15 %), malabsorption (3 % -5 %), and drug use (4 % -10 %) [2 -4].