Appropriateness of therapy for active Crohn's disease: results of a multidisciplinary international expert panel (EPACT II)

Introduction: The development of novel therapies and the increasing number of trials testing management strategies for luminal Crohn's disease (CD) have not filled all the gaps in our knowledge. Thus, in clinical practice, many decisions for CD patients need to be taken without high quality evidence. For this reason, a multidisciplinary European expert panel followed the RAND method to develop explicit criteria for the management of individual patients with active, steroid-dependent (ST-D) and steroid-refractory (ST-R) CD. Methods: Twelve international experts convened in Geneva, Switzerland in December 2007, to rate explicit clinical scenarios, corresponding to real daily practice, on a 9-point scale according to the literature evidence and their own expertise. Median ratings were stratified into three categories: appropriate (7-9), uncertain (4-6) and inappropriate (1-3). Results: Overall, panelists rated 296 indications pertaining to mild-to-moderate, severe, ST-D, and ST-R CD. In anti-TNF naïve patients, budesonide and prednisone were found appropriate for mildmoderate CD, and infliximab (IFX) when those had previously failed or had not been tolerated. In patients with prior success with IFX, this drug with or without co-administration of a thiopurine analog was favored. Other anti-TNFs were appropriate in case of intolerance or resistance to IFX. High doses steroids, IFX or adalimumab were appropriate in severe active CD. Among 105 indications for ST-D or ST-R disease, the panel considered appropriate the thiopurine analogs, methotrexate, IFX, adalimumab and surgery for limited resection, depending on the outcome of prior therapies. Anti-TNFs were generally considered appropriate in ST-R. Conclusion: Steroids, including budesonide for mild-to-moderate CD, remain first-line therapies in active luminal CD. Anti-TNFs, in particular IFX with respect to the amount of available evidence, remain second-line for most indications. Thiopurine analogs are preferred to anti-TNFs when steroids are not appropriate, except when anti-TNFs were previously successful. These recommendations are available online (www.epact.ch). A prospective evaluation of these criteria in a large database in Switzerland in underway to validate these criteria.

Notice d'estampes, gravures... provenant du fonds de M. Letouzé [éditeur, marchand d'estampes],...

[Vente. Estampes. 1854-12-22. Paris]

Evaluation of Recycled Rubber in Asphalt Concrete - Plymouth County, HR-330A, 1992

The Iowa Department of Transportation is evaluating the use of ground recycled crumb rubber from discarded tires in asphalt rubber cement. There were four projects completed during 1991 and another one constructed in 1992. This project is located on IA 140 north of Kingsley in Plymouth County. The project contains one section with reacted asphalt rubber cement (ARC) used in both binder and surface courses, one with reacted ARC used in the surface course and a conventional binder course, and a conventional mix control section. The reacted rubber binder course was placed on October 17, 1991 and the reacted rubber surface course was placed on October 17, 18, and 19. Inclement weather caused a slight delay in placing or constructing the surface. There was a minor problem with shoving and cracking of the binder course. The construction went well otherwise. Information included in this report consists of test results, construction reports, and cost comparisons.