Cause-specific excess deaths are associated with underweight, overweight and obesity, according to findings in last week's Journal of the American Medical Association.

Doctors from Maryland estimated cause-specific excess deaths associated with underweight (body mass index (BMI) less than 18.5), overweight (BMI 25 to 30 or less) and obesity (BMI 30). Cause-specific relative risks of mortality were assessed from the first National Health and Nutrition Examination Survey from 1971 to 1975, and from follow-up surveys from 1976 to 1980 and between 1988 and 1994. Mortality was followed up through 2000 for a total of 571,042 person-years. The team combined mortality data with data on BMI, and other covariates from National Health and Nutrition Examination Survey between 1999 and 2002. The researchers evaluated the underlying cause of death information for 2.3 million adults 25 years from 2004 vital statistics data for the U.S. The team evaluated cause-specific excess deaths in 2004 by BMI levels for categories of cardiovascular disease, cancer and all other causes.

Based on total follow-up, underweight was associated with significantly increased mortality from noncancer, non-cardiovascular disease causes, though it was not associated with cancer or cardiovascular disease mortality. The researchers found that overweight was associated with significantly decreased mortality from noncancer, non-cardiovascular disease causes. However, the team observed that overweight was not associated with cancer or cardiovascular disease mortality. Obesity was associated with significantly increased cardiovascular disease mortality, but was not associated with non-obesity related cancer mortality or with noncancer, and non-cardiovascular disease mortality. The team found in further analyses, that overweight and obesity combined were associated with increased mortality from diabetes and kidney disease. Overweight and obesity combined were associated with decreased mortality from other noncancer, non-cardiovascular disease causes. Obesity was associated with increased mortality from cancers considered obesity-related (including colon cancer), but not associated with mortality from other cancers. The team found comparisons across surveys suggested a decrease in the association of obesity with cardiovascular disease mortality over time.

A report in last week's New England Journal of Medicine shows that S-1, an oral fluoropyrimidine, is an effective adjuvant treatment for advanced gastric cancer.

Since advanced gastric cancer can respond to S-1, researchers tested it as adjuvant chemotherapy in patients with curatively resected gastric cancer. The research team identified patients in Japan with stage II or III gastric cancer who underwent gastrectomy with extended lymph-node dissection. The patients were randomly assigned to undergo surgery followed by adjuvant therapy with S-1 or to undergo surgery only. In the S-1 group, administration of S-1 was started within six weeks after surgery and continued for one year. The treatment regimen consisted of six-week cycles in which, in principle, 80 mg of oral S-1 per square meter of body-surface area per day was given for four weeks. No chemotherapy was given for the following two weeks. The team's primary end point was overall survival.

The team randomly assigned 529 patients to the S-1 group, and 530 patients to the surgery-only group between 2001 and 2004. The trial was stopped on the recommendation of the independent data and safety monitoring committee. The first interim analysis, performed one year after enrollment was completed, showed that the S-1 group had a higher rate of overall survival than the surgery-only group. Analysis of follow-up data showed that the three-year overall survival rate was 80 percent in the S-1 group, and 70 percent in the surgery-only group. The researchers found that the hazard ratio for death in the S-1 group, as compared with the surgery-only group, was 0.70. The team observed that adverse events of grade 3 or grade 4 relatively common in the S-1 group were anorexia, nausea and diarrhea.

Results in the November issue of the Journal of Pediatric Gastroenterology and Nutrition show that esomeprazole is well tolerated in adolescent patients with gastroesophageal reflux disease (GERD).

Researchers assessed the safety of esomeprazole 20 or 40 mg once daily in adolescents with clinically diagnosed GERD, with a secondary aim to assess changes in GERD symptoms after esomeprazole therapy. The team conducted a multicenter, randomized, double-blind study of 148 adolescents aged 12 to 17 years. The patients received esomeprazole 20 or 40 mg once daily for eight weeks and adverse events and changes in clinical parameters were evaluated to assess safety. Patients or their parents or guardians scored symptom severity daily and the investigators scored overall GERD symptom severity every two weeks using a four-point scale.

The investigative team found that safety data, treatment-related and non-treatment-related adverse events were reported by 75 percent and 78 percent of patients in the esomeprazole 20- and 40-mg groups, respectively. The team observed that 15 percent experienced adverse events that were considered related to treatment. The most common adverse events were headache, abdominal pain, nausea and diarrhea. No serious adverse events or clinically important findings in other safety assessments were observed. At baseline, the team noted that 68 percent had heartburn, 63 percent had epigastric pain, 57 percent had acid regurgitation and 15 percent had vomiting symptoms. Symptom scores decreased significantly in both the esomeprazole 20-mg and 40-mg groups by the final study week. The investigators rated 63 percent of the patients as having moderate or severe symptoms at baseline. At the final visit, this percentage decreased significantly to 9 percent.

A study in the latest issue of GIE: Gastrointestinal Endoscopy reports that the tortuous pattern determined by narrow-band imaging colonoscopy may be a clue for the identification of dysplasia during surveillance for ulcerative colitis.

Narrow-band imaging is a novel illumination technology for endoscopy that enhances vasculature of the gastrointestinal tract. Investigators from Japan elucidated whether narrow-band imaging colonoscopy can identify dysplasia in patients with ulcerative colitis. The team conducted a cross-sectional study of 46 patients with ulcerative colitis at a single center. Apparently flat mucosa at each segment and visible protruding lesions were observed by magnifying narrow-band imaging colonoscopy and the surface structure was classified into honeycomb-like, villous or tortuous pattern. The grade of dysplasia was determined in the specimens obtained from protrusions and from flat mucosa. The researchers then assessed the positive predictive value of conventional and narrow-band imaging colonoscopy for the diagnosis of dysplasia.

The researchers examined a total of 296 sites by narrow-band imaging colonoscopy. The surface pattern was determined to be honeycomb like in 161 sites, villous in 85 sites and tortuous in 50 sites. The research team detected five dysplastic lesions in three patients. The team found a patient had three dysplastic lesions, and the other two had a dysplastic lesion each. The positive rate of dysplasia was higher in protrusions than in flat mucosa sites; however, correction for the multiple testing of data removes this significance. When the surface pattern was taken into account, the rate of positive dysplasia was higher in the tortuous pattern than in the honeycomb-like or villous patterns.

On Nov. 10, the AGA, ASGE and ACG jointly sponsored the 11th Annual Medicare Carrier Advisory Committee (CAC) meeting in Washington, DC. Michael Weinstein, MD, served as a co-chair for the AGA. This meeting brings together all the GI representatives of the state carriers as one specialty and serves as a forum to discuss Medicare policy, coverage and coding issues around the country.

The GI CAC advisors role is to advise the carrier medical directors on a variety of local coverage and payment policies and also bring GI issues of concern to the medical directors. The advisors then educate members of their own specialty about these policies in their respective states.

This year's featured speakers included Lawrence Clark, MD, former Mid-Atlantic Medical Director for Trailblazer Medicare who spoke about Medicare Contractor Reform and the Medicare Administrative Contracts (MACs). Richard Wild, MD, JD, MBA, FACEP, Chief Medical Officer of CMS, Atlanta, spoke on the Physician Quality Reporting Initiative (PQRI and other quality issues.

CAC representatives were educated on changes in 2008 coding and reimbursement and upcoming issues to watch for in 2009 and beyond. R. Bruce Cameron, MD, provided a CPT update and Maurits Wiersema, MD, who recently began a two-year rotating seat on the AMA/Relative Value Update Committee (RUC) for gastroenterology, provided a RUC update.

There was also a panel discussion of the three societies on the Congressional environment and legislative activity under discussion to prevent the 10.1 percent physician payment cut. A regulatory update included information on the recent final rules on the physician fee schedule, ambulatory surgical centers and hospital outpatient departments.

CMS has released a special edition MLM article to clarify billing instructions for the Medicare beneficiary who:

1) Presents for a screening colonoscopy (or flexible sigmoidoscopy).
2) Has no gastrointestinal symptoms.
3) During their screening colonoscopy (or flexible sigmoidoscopy), have an abnormality identified (such as a polyp, etc.) which is biopsied or removed.

Effective Jan. 1, 2007, CMS waives the annual Part B deductible for colorectal cancer screening tests. Unfortunately, if the screening procedure turns in to a therapeutic procedure such as through biopsy or removal of a lesion, CMS has stated that the procedure cannot be coded as a screening and the deductible is no longer waived.

This interpretation has caused confusion on how to properly code this scenario. Regarding ICD-9-CM diagnosis coding, CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be the appropriate screening code. The secondary diagnosis code should be the ICD-9-CM code for the abnormal finding (polyp, etc.). The appropriate CPT code to use is the procedure actually performed, not a screening G code. Enter a "2" in Box 24E of the CMS 1500 to link the biopsy or polypectomy with the polyp.

The AGA continues to work to allow the deductible to be waived if a screening procedure results in a therapeutic procedure. AGA believes this was the intent of Congress and the beneficiary should not be penalized.

For the first time in nearly a decade, the AGA, ASGE, ACG, the American Medical Association (AMA), and more than 70 other medical specialty societies, have worked together to coordinate a comprehensive multi-specialty survey of America's physician practices. The purpose of the survey is to collect up-to-date information on physician practice characteristics in order to positively influence national decision makers. Thousands of practices will be surveyed in 2007 and 2008, from virtually all physician specialties to ensure accurate and fair representation for all physicians and their patients.

This project is unique because it explores both the clinical and business side of medical practice. This information is important for the nation's policy makers to learn what is truly involved in running a practice that provides expert patient care, while operating a business that is sustainable. A complete understanding of the landscape and the requirements for today's care is critical. These data will allow medicine to articulate practice concerns to national policy makers that will lead to policy initiatives that not only help in the short term, but will allow future generations of doctors to continue providing superior care to their patients.

There is a small section in this study pertaining to practice expenses and the amounts that are attributable to you. Please encourage your staff to make these numbers available. CMS recently announced that the results of this study are considered critical to update physician payment. This is a vital part of the research and we need to have accurate and complete data. This information remains confidential. The survey firm will not identify any individuals or entities participating in this research to any of the participating organizations.

dmrkynetec has been retained to conduct the Physician Practice Information survey among a representative random sample of practices in each of the participating specialties. The survey is an important and necessary vehicle for positive change. Please watch for this survey and do your part in completing it in a thorough and accurate manner if selected to represent our specialty.

Produced in cooperation with the AGA Institute, UpToDate^® is a subscription-based clinical information resource available on the Web, CD-ROM and Pocket PC handheld devices. Each month, a free topic is made available on the AGA Web Site. This month’s free topic is:

• Renal Disease with Hepatitis C Virus Infection

Nearly 232 physicians write more than 673 topic reviews for UpToDate in gastroenterology and hepatology alone. UpToDate provides gastroenterologists with access to more than 60,000 pages of original, peer-reviewed text, 160,000 MEDLINE abstracts, drug information and drug interactions databases, and hundreds of patient information handouts across 12 specialties. Moreover, UpToDate is used by tens of thousands of clinicians in more than 110 countries and by hundreds of premier medical institutions worldwide.

Order your subscription to UpToDate.

The AGA is proud to announce that 2005 Funderburg Recipient Jean-Marie Houghton, MD, PhD, University of Massachusetts Medical School Worchester, MA, recently received The Presidential Early Career Award for Scientists and Engineers (PECASE Award), which is the highest honor granted by the U.S. government to scientists beginning their independent research careers. Dr. Houghton received the award for "outstanding research showing that Helicobacter infection induces an inflammation within the stomach that attracts bone marrow derived stem cells, which differentiate inappropriately into meta- and dys-plastic epithelial cells and eventually act as cancer initiating cells."

The Presidential Awards are intended to recognize and nurture some of the finest scientists and engineers who, while early in their research careers, show exceptional potential for leadership at the frontiers of scientific knowledge during the twenty-first century. The Awards first and foremost support the continued development of the awardees, foster innovative and far-reaching developments in science and technology, increase awareness of careers in science and engineering, give recognition to the scientific missions of participating agencies, enhance connections between fundamental research and national goals, and highlight the importance of science and technology for the nation's future.

The editors of Gastroenterology and Clinical Gastroenterology and Hepatology would like to bring to your attention the following highlighted articles from the November issues of the journals:

Gastroenterology

• A Phase I Study of Visilizumab, a Humanized Anti-CD3 Monoclonal Antibody, in Severe Steroid Refractory Ulcerative Colitis; Scott Plevy, et al.

• Hypnotherapy for Children With Functional Abdominal Pain or Irritable Bowel Syndrome: A Randomized Controlled Trial; Arine M. Vlieger, et al.

• Entecavir Therapy for up to 96 Weeks in Patients with HBeAg-Positive Chronic Hepatitis B; Robert G. Gish, et al.

• Low Resistance to Adefovir Combined With Lamivudine: A 3-Year Study of 145 Lamivudine-Resistant Hepatitis B Patients; Pietro Lampertico, et al.

• Clearance of Hepatitis B e Antigen in Patients with Chronic Hepatitis B and Genotypes A, B, C, D and F; Stephen E. Livingston, et al.

Clinical Gastroenterology and Hepatology

• Intermittent Unexplained Abdominal Pain — Is It Porphyria?; Joseph R Bloomer, et al.

• Adult Autoimmune Enteropathy: Mayo Clinic Rochester Experience; Salma Akram, et al.

• Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Pancreatitis by an Endoscopic Pancreatic Spontaneous Dislodgement Stent; Atsushi Sofuni, et al.

• Functional Imaging of Colonic Mucosa With a Fibered Confocal Microscope for Real-Time In Vivo Pathology; Thomas D. Wang, et al.