Using strict pathologic definitions of invasive disease, a study in this month's issue of the Clinical Gastroenterology & Hepatology finds the true prevalence of invasive esophageal adenocarcinoma in Barrett's esophagus and high-grade dysplasia may have been overestimated significantly.

Recent studies have claimed long neoplasia-free survival rates with endoscopic mucosal resection of high-grade dysplasia in Barrett's esophagus. Reports have contended that approximately 40 percent of patients who have esophagectomy for high-grade dysplasia have occult invasive cancer. Doctors determined the true prevalence of invasive adenocarcinoma in patients who had esophagectomy for high-grade dysplasia in Barrett's esophagus, gathering studies reporting rates of esophageal cancer in patients who underwent esophagectomy for high-grade dysplasia in Barrett's esophagus using MEDLINE and PUBMED. The team defined invasive esophageal adenocarcinoma as tumor with submucosal invasion or beyond; intramucosal carcinoma was not considered invasive esophageal adenocarcinoma.

The researchers selected 23 articles for analysis. The pooled average for invasive cancer was 40 percent among the 441 patients who underwent an esophagectomy for high-grade dysplasia. Reported rates varied from 0 percent to 73 percent. A total of 267 patients had American Joint Committee on Cancer stage 0 postoperatively. The team identified 132 patients with stage I, 23 patients had stage IIa, 10 patients had stage IIb, and 9 patients had stage III. The research team reported that 14 studies provided differentiation between intramucosal and submucosal invasion. Among 213 patients, only 13 percent had invasive esophageal adenocarcinoma, whereas 87 percent had high-grade dysplasia or intramucosal carcinoma. The team found that the invasive esophageal adenocarcinoma rate of 11 percent among patients with visible lesions is greater than the rate of 3 percent among patients with no visible lesion.

A survey in this month's Colorectal Disease reports that the level of awareness of investigation modalities and treatment options for fecal incontinence is limited among general practitioners in the U.K.

Fecal incontinence is a distressing condition that can result in significant embarrassment and limitation of routine activities. General practitioners are the primary care givers for such patients and, though there are recent developments in the surgical treatment options for this under-reported condition, awareness of these changes is required to make the best use of them. Researchers in the U.K. examined the awareness of investigations and treatment options for fecal incontinence amongst general practitioners in the Yorkshire region. A questionnaire was designed to assess the basic knowledge of general practitioners with regard to prevalence, investigations and treatment of fecal incontinence. The patterns of consultations and referrals of patients with fecal incontinence were also evaluated.

Of 1,100 posted, the research team reported that 504 questionnaires were returned, giving a response rate of 49 percent. The prevalence assessed by the general practitioners is similar to that by population based surveys. The team found only 32 percent of general practitioners were aware of at least one investigation. Similarly, only 32 percent of the general practitioners were aware of at least one form of surgical treatment. The team found the knowledge of centers where these facilities are available was limited, as 60 percent were not aware. Only about 25 percent of the general practitioners referred the patients to the surgical specialties. The team observed no difference in awareness between the general practitioners who see patients with fecal incontinence more frequently compared with those who see such patients infrequently.

Liver cirrhosis and hepatic decompensation events are relatively frequent in HIV-positive individuals, according to a report in the March issue of the Journal of Viral Hepatitis, while chronic hepatitis C virus and alcohol abuse, but not chronic hepatitis B virus, play major roles.

Liver disease is frequently seen in HIV-positive patients as a result of co-infection with hepatitis B or hepatitis C viruses, alcohol abuse and/or exposure to hepatotoxic drugs. Doctors assessed the prevalence of liver cirrhosis, its main causes and clinical presentation in HIV-positive patients, conducting an observational, cross-sectional, retrospective study of all HIV-positive individuals followed at one reference HIV outpatient clinic in Madrid. The team measured liver fibrosis in all cases using transient elastometry. All 2,168 HIV-positive patients on regular follow-up were successfully examined between 2004 and 2006. The team recognized liver cirrhosis in 181 patients, an overall prevalence of 8 percent. The main etiologies included hepatitis C virus infection in 82 percent, and hepatitis B virus in 2 percent. In addition, the team noted that dual hepatitis B virus/hepatitis C virus occurred in 3 percent; triple hepatitis B virus/hepatitis C virus/hepatitis delta virus infection was found in 7 percent.

The researchers found that the prevalence of cirrhosis differed among patients with distinct chronic viral hepatitis. Hepatitis C virus occurred in 19 percent, hepatitis B virus in 6 percent, and hepatitis B virus/hepatitis C virus in 42 percent of patients with distinct chronic viral hepatitis. The team observed that triple hepatitis B virus/hepatitis C virus/hepatitis delta virus infection was the cause of chronic viral hepatitis in 67 percent. In 7 percent of patients with cirrhosis, no definite etiology was recognized. The team found that overall, cirrhotics had lower mean CD4 counts than noncirrhotics. The research team noted the lower CD4 count despite similar proportion of subjects with undetectable viremia on highly active antiretroviral therapy. The team found clinical manifestations of liver cirrhosis included splenomegaly, esophageal varices, ascites, encephalopathy and variceal bleeding.

Findings in the most recent issue of Liver Transplantation evaluate the risk for relapse to substance use after liver transplantation.

For patients receiving liver or other organ transplants for diseases associated with substance use, risk for relapse post-transplantation is a prominent clinical concern. There is little consensus regarding either the prevalence or risk factors for relapse to alcohol or illicit drug use in these patients. Moreover, the evidence is inconsistent as to whether patients with pretransplantation substance use histories show poorer post-transplantation medical adherence. Researchers in the U.S. conducted a meta-analysis of studies published between 1983 and 2005. The research team estimated relapse rates, rates of nonadherence to the medical regimen, and the association of potential risk factors with these rates.

The team reported that the analysis included 54 studies. Average alcohol relapse rates were six cases per 100 patients per year. Relapse rates were three cases per 100 patients per year for heavy alcohol use. The researchers found illicit drug relapse averaged four cases per 100 patients per year, with a significantly lower rate in liver versus other recipients. Average rates in other areas, such as tobacco use and nonadherence to both immunosuppressants and clinic appointments, were two to 10 cases per 100 patients per year. The team found that risk factors could be examined only for relapse to any alcohol use. Demographics and most pretransplantation characteristics showed little correlation with relapse. Poorer social support, family alcohol history and pretransplantation abstinence of six months showed small but significant associations with relapse.

As recently reported in AGA eDigest, CMS has delayed the applicability of the anti-markup provisions that it announced in the 2008 physician final rule until Jan. 1, 2009. However, that delay did not apply to pathology services. CMS was concerned about anatomic pathology diagnostic testing services furnished in a space used by a physician group practice as a "centralized building." These provisions were intended to close a perceived loophole in the self-referral regulations that had allowed the operation of off-site "pod labs."

Several urology groups filed suit in U.S. District Court against the U.S. Department of Health and Human Services over the application of the anti-markup provisions as they related to pathology services performed in centralized buildings. Recently, he urology groups received a successful court ruling on their motion. The U.S. District Court for the District of Columbia has ordered a delay in the application of the anti-markup rule for pathology services, and has ruled that CMS will not apply the final anti-markup provisions as it relates to anatomic pathology diagnostic testing services that are furnished in a centralized building that does not qualify as the "same building" under the physician self-referral exception for claims submitted between Feb. 1 and April 1, 2008. If the Court reaffirms the anti-markup rule for pathology services at a later date, CMS cannot recoup any Medicare payments for claims submitted during that time period.

This court ruling by the U.S. Distrcit Court will impact gastroenterology practices that perform pathology services in centralized buildings. Future court action on the anti-markup rule will be announced in AGA eDigest.

The Bush administration proposed additional changes to the Medicare program this week in response to a federally mandated Medicare funding warning. The warning is reported to the administration by the Medicare trustees whenever general revenue spending for Medicare exceeds 45 percent two years in a row. The funding warning trigger mandate was included as part of the Medicare Modernization Act (MMA) and requires the administration to send Congress legislation in response to the trigger.

In addition to the $183 billion in cuts to the Medicare program included in Bush's budget, the administration is also proposing higher income beneficiaries pay more for Part D drug coverage. The proposal would also require HHS to establish health information technology (HIT) requirements for electronic medical records and e-prescribing, transparency pricing information and monetary incentives for delivering quality care. The administration would also place caps of $250,000 for non-economic damages in medical malpractice cases.

The MMA provision requires that the president's legislation must be voted on in the House and Senate by June 30, but Congress will likely make changes to the proposal. Although the president's budget cuts, and elements of this legislation, were met with opposition from congressional Democrats, some have indicated there may be room for compromise on such issues as HIT, e-prescribing and paying for quality health care.

The AGA Institute will accept late-breaking abstracts from Friday, Feb. 15 through Friday, March 14, 2008 at 5 p.m. Don't miss out on this opportunity to have your late-breaking research presented at DDW^® 2008 in San Diego.

Abstracts will not be accepted if they have been published as an article before May 20, 2008, or have been presented in the U.S. at a national meeting of any society (with the exception of the ACS Surgical Forum). However, abstracts will be considered for presentation if they were presented at national meetings in countries outside the U.S.

Abstracts must be submitted electronically via the DDW online abstract submitter at ddw2008.abstractcentral.com. The AGA Institute Council will review and select up to six clinical abstracts for oral presentation — authors will be notified on March 31 regarding acceptance. The selected abstracts will be presented in a symposium at the San Diego Convention Center during DDW 2008 on Tuesday, May 20. Basic abstracts selected will be presented as posters of distinction.

Accepted abstracts will also be published in the April issue of Gastroenterology. The deadline for submission is 5 p.m. ET on March 14, 2008. Authors do not have to be an AGA member.

Apply for GRG Travel Awards

Annually, the Gastroenterology Research Group (GRG), in collaboration with the AGA, awards travel grants to promising young investigators and trainees with the goal of encouraging trainees to become more involved in digestive disease research.

The GRG/AGA Fellow Travel Award provides travel grants to individuals chosen to present outstanding abstracts, of which they are first authors, at DDW^®. Qualified applicants are MD or PhD postdoctoral fellows. Applicants must be sponsored by a member of the AGA and the GRG and must apply by March 21. The recipient of the GRG/AGA Abstract of the Year Award is selected by the GRG from among the applications submitted for the GRG/AGA Fellow Travel Awards.

In addition, the GRG/AGA Young Investigator Clinical Science Award and the GRG/AGA Young Investigator Basic Research Award recognize the specific achievements of young clinical investigators and young basic research scientists whose focus is in the area of digestive and/or liver diseases. Nominees must be independent investigators who have held an independent faculty position at the level of Assistant Professor or higher for less than seven years, and are AGA and GRG members.

For complete details about the Young Investigator, Fellow Travel and Abstract of the Year Awards, please visit the GRG’s Web site at www.gastroresearch.org.

Research funding opportunities are abundant during the upcoming month. The Foundation for Digestive Health and Nutrition offers numerous grants for researchers at all levels, from high school students to established investigators. Applications for the following awards are due now through March 21:

Students

• Graduate Student Awards fund graduate students undertaking doctoral research in diseases of the gastrointestinal tract, liver or pancreas. Due March 14.
• Student Abstract Prizes are awarded to high school, college, graduate and medical students whose abstracts have been accepted for presentation at DDW^®. Due March 21.
• Student Research Fellowship Awards support high school, undergraduate, medical or graduate students performing digestive disease or nutrition research for a minimum of 10 weeks. Due March 5.

Junior Investigators

• AGA Institute International Travel Award funds travel expenses for investigators with less than five years of training who reside outside North America and are presenting an abstract at DDW. Due March 21.
• Fellow Abstract Prizes will be given to two fellows whose abstracts have been accepted by the AGA Institute for presentation at DDW. Due March 21.
• Moti L. & Kamla Rustgi International Travel Awards help young basic, translational and clinical investigators residing outside the U.S. with their travel and related expenses to attend DDW. Due March 21.

Established Investigators

• The new AGA Institute CTC Planning Grants aim to reduce barriers and promote the collaboration of two or more investigators that will lead to innovations in understanding the optimal use of CT colonography. Apply Now — Due Feb. 23!
• Translational Research Award provides two years of financial support for translational research in gastroenterology and/or hepatology. Due March 14.

Please visit the Foundation Web site at www.fdhn.org for complete award criteria, applications and information.

Effective March 1, 2008, when required for submission of Medicare claims, all CMS-1500 claims must have a National Provider Identifier (NPI) in the required primary provider fields.

Claims without an NPI in the primary provider field will be rejected. Claims with only a Medicare legacy number (i.e. Provider Identification Number) in the primary provider field will be rejected. This means that you will not be able to get paid for any Medicare services you provide until you begin using your NPI.

View detailed information on this requirement.

Medicare legacy provider numbers will become prohibited on CMS-1500 forms after the NPI required date of May 23, 2008. After that date, claims submitted with legacy numbers will be returned as not processable. For additional background see: www.cms.hhs.gov/MLNMattersArticles/downloads/MM5858.pdf

The NPI — a requirement under the Health Insurance Portability and Accountability Act (HIPAA) — is a unique 10-digit identification number for covered health-care providers. Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI was required in lieu of legacy provider identifiers in the HIPAA standards transactions. If you are a health-care provider who bills for services, you probably need an NPI and for Medicare billing, an NPI is required.

For information on obtaining an NPI, visit the CMS Web site.

The AGA Center for GI Practice Management and Economics is an all-inclusive resource for meeting the practice management needs of private practice and clinical academic gastroenterologists and their staff. Under the leadership of the AGA Institute Practice Management and Economics Committee, the Center offers an extensive array of products, services and educational opportunities, providing a comprehensive approach to practice management success. Each resource is designed to help you increase revenue, reduce billing and coding errors, and maximize practice efficiency.

Resources include:

• INTELICODE^® Software – places key coding and auditing resources in one searchable location, improving efficiency and overall accuracy.
• AGA GI Coding and Billing Answer Line – your source for answers to your coding and billing questions.
• Year-round educational programs – offering audio conferences, webcasts and live workshops.
• GI Quality and Practice Management News – a monthly e-newsletter updating you on the most important practice management news, including government regulations, quality-of-care measurements and valuable strategies for improving patient, physician and staff satisfaction.

The Center is your one-stop shop for GI practice management resources. View a full list of resources at www.gastro.org/center.

The AGA Institute 2008 Spring Postgraduate course, Gastroenterology and Hepatology 2008: Challenges and Controversies, will present attendees with new insight into the challenging and controversial issues surrounding major GI and liver disorders. Sessions will address topics such as CT colonography, non-alcoholic fatty liver disease, IBD, gut microflora and probiotics, and hepatocellular carcinoma screening. Those who cannot attend the course or who want to enhance their learning experience can purchase valuable reference tools, including a syllabus, CD-ROM and online subscription to the sessions.

The course syllabus, which is available at DDW^® and free to course attendees, contains comprehensive details of all sessions, including abstracts, key points, references, slides, graphs, charts and tables. Learning objectives and complete reference lists are also included.

The online sessions and the CD-ROM contain the complete audio track of all the lectures and clinical challenge sessions as well as corresponding slides. Both are fully searchable by topic or author and the online sessions offer CME credit. Sessions from the course will be available online after Aug. 15 and on CD-ROM after Sept.1. Buyers can save with a special offer that gives them access to the online sessions for just $10 with their CD-ROM purchase.

While supplies last, the CD-ROM and syllabus for the AGA Institute 2007 Spring Postgraduate course, 21st Century Tools for Managing Gastrointestinal and Liver Disease, are available at a discounted price.

Pre-order these valuable resources by April 11 and save 10 percent. Visit the Education & Training section of www.gastro.org or request an order form by calling AGA Member Services at (301) 941-2651. For more information about this year’s Spring Postgraduate course, visit www.gastro.org/pgcourse.

The AGA Institute's GastroSlides (formerly the Gastroenterology Teaching Project) provides you with maximum flexibility in creating customized presentations with high-quality images. New pricing options allow you to buy slides individually as you need them, or purchase a subscription, giving you access to the entire GastroSlides library for one year. Developed by internationally renowned experts, GastroSlides is a valuable resource to help you explain complex concepts and processes of digestive diseases in presentations and lectures.

With over 3,000 images in its repository, GastroSlides offers you:

• The ability to search by keyword or topic to help you quickly and easily locate slides relevant to your needs.
• The flexibility to prepare new individualized slides using the components of existing images to create customized slides for different lectures.
• An extensive citation resource that can be used for lectures and serve as a permanent reference tool.

More than 1,500 GastroSlides images cover liver disease topics, such as hepatocelluar carcinoma, autoimmune liver disease, cirrhosis and portal hypertension, non-alcoholic fatty liver disease, and viral hepatitis. GI topics include pancreatitis, IBD, IBS, Barrett's esophagus, and the genetic and molecular basis of gastrointestinal and liver disease.

View and order slides from www.gastroslides.org.

Note: A limited number of CD-ROMs are still available.

GastroSlides is a continuing education resource directed by the Education and Training Committee of the AGA Institute.