Will endoscopic global fees destroy gastroenterology as a specialty?

The Health Care Financing Administration (HCFA) has recently proposed a plan, effective July 1, 1991, for Medicare to pay for endoscopic procedures according to a global fee arrangement. Under global fees, the charges for any hospital or office visits for 30 days after endoscopy will be considered to be included in the Medicare payment for the endoscopic procedure. Global endoscopy fees depreciate the nonprocedural aspects of the gastroenterologist's care. In concert with other physician income reduction provisions of the 1989 and 1990 Omnibus Budget Reconciliation Acts, global endoscopy fees will dramatically alter the future behavior of gastroenterologists and their attitude toward Medicare patients. The deadline for writing HCFA has passed, but concerned gastroenterologists should protest this plan at once to their Senators and Congressional Representatives.

Duodenal epithelial thymidine uptake in patients with duodenal ulcer or endoscopic duodenitis.

To evaluate the relationship between duodenal ulcer disease and duodenitis, duodenal epithelial cell renewal was measured in mucosal biopsies by the incorporation of [3H]thymidine. When 14 patients with duodenal ulcer were compared to 13 control subjects or 7 with endoscopic duodenitis alone, the crypt size was the same in all groups. Similar to other inflammatory processes of the gastrointestinal tract, patients with endoscopic duodenitis showed increased proliferative indices including a greater number of cells incorporating [3H]thymidine. In contrast, the proliferative indices from the duodenal mucosa of patients with duodenal ulcers did not differ from a control group. In a group of 6 patients with both endoscopic duodenitis and duodenal ulcer, the [3H]thymidine incorporation was intermediate between control subjects or patients with duodenal ulcer alone and those with endoscopic duodenitis alone. When subjects were divided according to the histologic appearance of the duodenal mucosa, those having chronic duodenitis demonstrated enhanced [3H]thymidine incorporation in comparison to a control group or patients with chronic active duodenitis (polymorphonuclear leukocytes present). Although there are many possible explanations of these findings, one may speculate that duodenal ulceration does not stimulate duodenal epithelial proliferation.

Routine clinical chemistries as improved determinates of prognosis for patients with metastatic cancer of the stomach.

Pretreatment total serum protein of less than 6 g%, serum glumatic oxaloacetic transaminase (SGOT) greater than 40 mU/ml or a total serum bilirubin greater than 0.6 mg% predicted a bad prognosis for patients with metastatic gastric cancer. If two of these objective laboratory tests predicted a good prognosis, partially nonambulatory patients lived an additional 20 weeks (median survival 27.9 vs 8.7, p less than 0.001) and patients with no clinically recognized liver metastases lived an additional 22 weeks (median survival 34.2 vs. 12.4, p less than 0.001). Patients with liver metastases lived an additional 11 weeks (median survival 20.9 vs. 9.6, p less than 0.001). These objective laboratory tests improve the assessment of patients in clinical trials. The model corrected a false assessment of a poor prognosis for 38% of all patients and 64% of patients with liver metastases.

The histopathologic and clinical indicators of prognosis in hepatoma.

Two histopathologic subtypes of hepatoma, clear cell type and fibrolamellar type, have been reported to indicate a longer survival. Although data on the prognostic value of clear cell histology is equivocal, evidence for prolonged survival (mean survival: 32-68 months) for patients with fibrolamellar type is impressive. Aggressive surgical intervention, including resection of metastases, appears indicated in fibrolamellar hepatocellular carcinoma. Bilirubin determination may be a reliable indicator of survival, but conflicting results are reported for most reputed clinical prognostic markers. Discrepancies may reflect regional and ethnic differences in the pathogenesis of hepatoma. We present an illustrative case of fibrolamellar hepatoma discovered in a 24-year-old woman with migratory thrombophlebitis. The patient successfully underwent an extended right hepatic lobectomy and is currently free of disease. We review the histopathologic and clinical prognostic features of fibrolamellar carcinoma and hepatoma.

Systemic lupus erythematosus and gastric carcinoma: a report of two cases and a critical review of the literature.

Two cases of systemic lupus erythematosus in association with primary gastric adenocarcinoma are presented. A pathological analysis of the two cases of gastric cancer does not support the hypothesis that lupus and its associated vasculitis is involved in the pathogenesis of gastric carcinoma. A critical review of the literature reveals numerous case reports suggesting the association of systemic lupus erythematosus with various malignancies; however, there is no definitive study which substantiates the association of gastric or other cancers with lupus. Future studies will be required to assess appropriately the possibility of an association between lupus and cancer.

Absolute granulocyte, lymphocyte, and moncyte counts. Useful determinants of prognosis for patients with metastatic cancer of the stomach.

Pretreatment absolute granulocyte (less than 6,000/cu mm), lymphocyte (greater than 1,500/cu mm), and monocyte (300 to 900/cu mm) counts are three independent indicators of good prognosis for patients with metastatic gastric cancer. There tests improve the prediction of survival significantly compared with estimates based on ambulatory status alone. If the patient is completely ambulatory, median survival (MS) is 27.6 weeks, and it improves further to 37.6 weeks if results of two hematology tests indicate a good prognosis. If the patient is partially ambulatory, MS is 16.2 weeks; however, if results of two blood tests indicate a good prognosis, MS is 25.7 weeks, and if two tests indicate a poor prognosis, MS is only 11.1 weeks. The model corrected a false assessment of a poor prognosis for 56% of all patients.

Therapy of locally unresectable pancreatic carcinoma: a randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil), and high dose radiation + 5-fluorouracil: The Gastrointestinal Tumor Study Group.

One-hundred-ninety-four eligible and evaluable patients with histologically confirmed locally unresectable adenocarcinoma of the pancreas were randomly assigned to therapy with high-dose (6000 rads) radiation therapy alone, to moderate-dose (4000 rads) radiation + 5-fluorouracil (5-FU), and to high-dose radiation plus 5-FU. Median survival with radiation alone was only 51/2 months from date of diagnosis. Both 5-FU-containing treatment regimens produced a highly significant survival improvement when compared with radiation alone. Forty percent of patients treated with the combined regimens were still living at one year compared with 10% of patients treated with radiation only. Survival differences between 4000 rads plus 5-FU and 6000 rads plus 5-FU were not significant with an overall median survival of ten months. Significant prognostic variables, in addition to treatment, were pretreatment performance status and pretreatment CEA level.

Early proliferative activity: its occurrence in the crypts of small bowel and colon after partial small-bowel resection.

Crypt population kinetics in both small bowel and colon were determined in the early postoperative period in the rat after either sham resection or resection of 50% of the midportion of the small bowel. A proliferative response was evident in the colon within 24 hours. This response of the labeling index was statistically significant in the left colon by comparison with the sham-resected animals, whereas in the right colon it was significant by comparison not only with the sham-resected but also with the intact animals. A proliferative response was documented in the remnants of the small bowel on the third postoperative day by comparison with those of the sham-resected animals. These findings indicate that adaptive hyperplasia begins very promptly in the intestinal remnants after partial resection.

Cancer of the pancreas: diagnostic accuracy and survival statistics.

We have reviewed the natural history, reliability of diagnosis, and survivorship of 100 patients with adenocarcinoma of the pancreas, in the context of a thorough review of the literature on survival after therapy for adenocarcinoma of the pancreas. There is 40--62.5% error in the histologic confirmation of the diagnosis of pancreatic cancer. The error by inspection and palpation alone at the time of surgery may be as great as 25%. The absolute 5 year survival rate calculated from 61 clinical studies representing approximately 15,000 patients is 0.4%. The best series in the current literature has only 3% 5 year rate based upon the total population of pancreatic cancer patients. 12.3% of 5 year survivors from the world literature did not have curative surgery. This study shows the necessity for standardization of reporting methods. The same patients and survivors should not be used repeatedly in different reports. Some authors who claim the most effective palliation by pancreatic resection have the highest mortality rates.

Randomized phase II clinical trial of adriamycin, methotrexate, and actinomycin-D in advanced measurable pancreatic carcinoma: a Gastrointestinal Tumor Study Group Report.

Sixty-six patients with advanced pancreatic carcinoma were randomized to receive single agent chemotherapy with either adriamycin, methotrexate, or actinomycin-D using conventional dose, route and schedule of administration. All patients had measurable lesions which were used to objective assessment of response. For adriamycin, 2 of 25 patients (8%) evidenced a partial response (2 of 15 (13%) previously untreated patients). One of 25 patients treated with methotrexate and one of 28 received actinomycin-D responded. The duration of responses ranged from 43-64 days for those patients with no chemotherapy prior to study entry. The median survival of patients who received adriamycin as initial treatment was 12 weeks compared to 8 weeks for methotrexate and 6 weeks for actinomycin-D therapy.

Value of a single forceps biopsy of colonic polyps.

The accuracy of colonoscopic biopsies in predicting the histological diagnosis of colonic polyps removed at colonoscopy or at laparotomy was studied. Forty-two patients were colonoscoped before the removal of 50 polyps. A single fractional biopsy was obtained from each lesion with the standard endoscopic biopsy forceps and was compared to the final histological diagnosis of each excised lesion. Thirteen (26%) of the singular fractional biopsies did not demonstrate the significant histological features of the excised polyps. These tiny biopsies do not adequately represent the entire polyp. Moreover, the 2- to 3-mm size of the biopsy does not permit the study of the central submucosal area of the polyp stalk, the critical area for assessing invasive malignancy. Histological examination of a completely excised polyp is essential for accurate diagnosis and appropriate therapy.

Studies of esophageal epithelial cell proliferation in patients with reflux esophagitis.

Accelerated cell turnover has been held responsible for the basal zone thickening of the esophageal squamous mucosa of patients with reflux esophagitis. We have studied the in vitro proliferative activity of the basal zone in suction biopsy specimens obtained from normal subjects, from patients with medically treated esophagitis, and from patients who had previously undergone anterior fundoplication. In patients with severe esophagitis, the basal zone showed a significantly elevated [3H]thymidine labeling index in contrast to that of mild esophagitis patients and that of normal subjects. When esophagitis was associated with mucosal lesions at endoscopy, the labeling index was higher than that seen in esophagitis patients without endoscopic abnormalities. Significantly increased thymidine labeling was found only in patients with the most severe changes of papillary length or basal layer thickening. We therefore conclude that there is an increased basal zone uptake of [3H]thymidine in severe esophagitis which suggests increased cell turnover as the mechanism for basal zone hyperplasia. Present techniques for measuring mucosal uptake of [3H]thymidine, however, do not permit the distinction of mild degrees of esophagitis from normal epithelium.