Doege-Potter Syndrome: A Solitary Fibrous Tumor Causing Non-Islet Cell Tumor Hypoglycemia

Doege-Potter syndrome occurs when incompletely processed insulin-like growth factor 2 (IGF-2), also known as big IGF-2, is produced by a solitary fibrous tumor (SFT) and results in non-islet cell tumor hypoglycemia (NICTH). We discuss here the case of a 66-year-old male who presented with a 2-week history of increasing confusion and a serum glucose of 34 mg/dL. The patient's symptoms immediately improved with dextrose. The patient did not use insulin, serum sulfonylurea screen was negative, and testing for adrenal insufficiency was unremarkable. Outpatient laboratory evaluation revealed a serum glucose of 48 mg/dL along with low insulin, C-peptide, and proinsulin levels. Further work-up showed an IGF-2 to IGF-1 ratio of 38:1. A ratio greater than 10:1 is diagnostic of NICTH. Imaging demonstrated a 21-cm mass in the lower abdomen and pelvis. The patient underwent surgical resection. The hypoglycemia resolved immediately postoperatively. Surgical pathology revealed a malignant SFT. In NICTH, big IGF-2 forms a complex that is biologically active and saturates the insulin and IGF receptors, resulting in refractory hypoglycemia. Although glucocorticoids can mitigate hypoglycemia, complete surgical resection is the only definitive treatment of NICTH. This case highlights the importance of maintaining a broad differential for seemingly simple hypoglycemia.

Real-World Evidence to Evaluate the Efficacy and Safety of Vonoprazan in Gastrointestinal Disorders in the Pakistani Population

BACKGROUND AND AIM

While proton pump inhibitor (PPI) therapy has proven to be effective in managing gastroesophageal reflux disease (GERD), a notable portion of patients who experience GERD symptoms may not respond to this treatment. Research suggests that roughly 30% of individuals with a presumed GERD diagnosis may continue to experience symptoms, whether partially or completely, even when receiving PPI therapy. The aim of this study was to assess the treatment of gastrointestinal diseases with a novel potassium-competitive acid blocker (P-CAB), vonoprazan, in terms of its effectiveness and safety in the Pakistani population.

METHODS

This prospective, multicenter, observational study was conducted in Pakistan. This study included 1,642 patients from January 2023 to August 2023, aged 18 years, with gastrointestinal disorders. All demographic data, medical history, GERD severity assessment questionnaire (GerdQ), and laboratory parameters, including stool assessment for Helicobacter pylori (H. pylori), were observed. Patients were orally treated with vonoprazan at doses of 10 mg or 20 mg, once or twice daily. Statistical analysis was done by one-way ANOVA.

RESULTS

Out of 1,642 patients, 840 (51.2%) were males and 802 (48.8%) were females, with a mean age of 39.81±14.61 years. The mean GerdQ score at baseline was 20.37±15.87, 7.24±8.15 at the second week of treatment, and 3.70±6.31 at the fourth week of treatment (p<0.001). 90.74% of patients achieved H. pylori eradication. Most patients were acid regurgitation and heartburn-free for >70% of days. Most of the patients, 1,283 (78.13%), exhibited good treatment compliance. Mild adverse events were reported in 37 (2.3%) patients.

CONCLUSIONS

The use of vonoprazan significantly reduced the likelihood of GERD by improving symptoms and was also highly effective in the elimination of H. pylori infections. Vonoprazan was generally well tolerated.

Prostate Tumor Regression during Radiation Therapy in Relation to Image Derived Estimates of Fibrosis Using Ultrashort Echo Time MRI

PURPOSE/OBJECTIVE(S)

An inflammatory response due to radiation injury can lead to the activation of fibroblasts and their transformation into myofibroblasts that produce organized collagen layers. We term these organized collagen layers "acute fibrosis" (FA). Small animal imaging has shown that accumulation of fibrosis is accelerated at a higher radiation dose with later remodeling of type III collagen into densely packed type I collagen structures, which later transform into what we term "chronic fibrosis" (FC). In prostate cancer (PCa) patients treated with EBRT, we evaluated image derived FA (IDFA) and FC (IDFC) estimates using non-contrast and late gadolinium contrast enhanced (LGE) IR UTE, respectively. We hypothesized that fibrosis changes during RT are associated to tumor regression.

MATERIALS/METHODS

Four PCa patients undergoing radiation and hormone suppression were included. 1.5T MR imaging was acquired at three time-points (TPs); pre-RT, on-RT (30-40 Gy), and post-RT (60-78 Gy). IDFA imaging: Stack of spirals dual echo (TE = 50, 2690µs, TI = 60ms) IR UTE research application. Subtracting the two echoes yielded short TE signal intensity (SI). IDFC imaging: stack of spirals dual echo IR UTE research application, TE = 50µs, TI = 200ms, acquired 15 minutes following Gadovist administration. Remnant tumor was contoured at each TP with T2, ADC, and DCE. Relative quantification; IDFA = IR UTE SI/Gluteal Muscle SI and IDFC = LGE IR UTE SI/Gluteal Muscle SI. The sum of normalized IDFA and IDFC SI within the remnant tumor at each TP was divided by the corresponding tumor volume yielding tumor intensity (TI) FA and FC accumulation estimates: TIFA and TIFC. Mean delivered dose within the treated volume to regions where post-RT IDFA and IDFC > 100% gluteal muscle SI was determined. Univariate relationships were evaluated using correlation coefficients (r).

RESULTS

The coefficients of variation for TIFA = 10% and TIFC = 11%. IDFA and IDFC were observed pre-RT on the prostate gland periphery, and on RT and post RT within the prostate gland. IDFA and IDFC mean doses were 74% and 85% of prescription, respectively. Tumor regression was incomplete by post-RT. Initial tumor burden was inversely correlated with pre-RT TIFC (r = -0.98, p = .01). Tumor volume change post RT was inversely correlated with larger on-RT TIFA (r = -0.76) and post-RT TIFC (r = -0.78).

CONCLUSION

In this small pilot study, results suggest that IDFA and IDFC may be associated with improved tumor regression. They also suggest higher delivered dose is related to regions of greater IDFC. Quantitative fibrosis may be an early marker of RT response. Caution must be taken when interpreting these results given the small sample size. Future work will include a larger cohort of patients and include post-RT imaging.

Image Derived Estimates of Fibrosis Using Ultrashort Echo Time MRI in Gynecologic Cancer

PURPOSE/OBJECTIVE(S)

Fibrosis forms during and after radiation therapy (RT) due to wound-healing and cell death. In gynecologic cancer patients treated with EBRT and HDR, we evaluated image derived (ID) acute fibrosis (IDFA) and chronic fibrosis (IDFC) estimates using non-contrast and late gadolinium contrast enhanced (LGE) inversion recovery ultrashort echo time (IR UTE) MRI, respectively. We hypothesized that that ID markers can quantify FA and FC within tumor as a result of response to RT and that fibrosis changes over the course of RT are associated with tumor regression.

MATERIALS/METHODS

Subjects: Three subjects with cervical squamous cell carcinoma (SCC), 1 subject with cervical adenocarcinoma, and 2 subjects with vaginal SCC undergoing RT were included. Image Acquisition & Analysis: 1.5T MR imaging at four time-points (TPs): pre-RT, on-RT, post-RT, and post 3mo RT. IDFA imaging: Stack of spirals dual echo (TE = 50, 2690µs), TI = 60ms IR UTE research application. Subtracting the two echoes yielded short TE signal intensity (SI). IDFC imaging: stack of spirals dual echo IR UTE research application, TE = 50µs, TI = 200ms, acquired 15 minutes following contrast. Remnant tumor was contoured at each TP with T2, ADC, and DCE. Relative IDFA, IDFC quantification: voxel-wise IR UTE and LGE IR UTE signal intensity (SI) normalized to gluteal muscle SI. The sum of normalized IDFA and IDFC SI within the remnant tumor at each TP was divided by the corresponding tumor volume yielding tumor intensity (TI) TIFA and TIFC fibrosis accumulation estimates.

STATISTICS

The coefficients of variation (COV) for TIFA and TIFC were calculated by varying tumor margins and re-computing TIFA and TIFC. Univariate relationships were evaluated using linear regression.

RESULTS

The COVs for TIFA = 13% and TIFC = 7%. IDFA and IDFC were observed pre-RT on the tumor periphery, on-RT and post-RT within the tumor, with IDFA potentially transforming into IDFC. Table 1 shows that a greater decrease in tumor volume post RT was correlated with a larger pre-RT TIFA (r = -0.85, p = .03). Decrease in tumor volume was correlated with a larger TIFC post-RT (r = -0.79, p = .05). Post 3 month TIFC was associated with tumor reduction (r = 0.82, n = 4).

CONCLUSION

In this pilot study, we developed reproducible methods to quantify IDFA and IDFC within remnant tumor. Our results suggest that IDFA and IDFC may be associated with tumor response based on tumor volume.

Dry Powder Formulation of Azithromycin for COVID-19 Therapeutics

Aim: The aim of this study is to develop dry powder formulations of azithromycin-loaded poly(lactic-co-glycolic acid) (PLGA) nanocomposite microparticles for pulmonary delivery to improve the low bioavailability of azithromycin. Methods: Double emulsion method was used to produce nanoparticles, which were then spray dried to form nanocomposite microparticles. Encapsulation efficiency and drug loading were analysed, and formulations were characterised by particle size, zeta potential, morphology, crystallinity and in-vitro aerosol dispersion performance. Results: The addition of chitosan changed the neutrally-charged azithromycin only formulation to positively-charged nanoparticles. However, the addition of chitosan also increased the particle size of the formulations. It was observed in the NGI® data that there is an improvement in dispersibility of the chitosan-related formulations. Conclusion: It was demonstrated in this study that all dry powder formulations were able to deliver azithromycin to the deep lung regions, which suggests the potential of using azithromycin via pulmonary drug delivery as an effective method to treat COVID-19.

Non-alcoholic Fatty Liver Disease and Depression: Evidence for Genotype × Environment Interaction in Mexican Americans

This study examines the impact of G × E interaction effects on non-alcoholic fatty liver disease (NAFLD) among Mexican Americans in the Rio Grande Valley (RGV) of South Texas. We examined potential G × E interaction using variance components models and likelihood-based statistical inference in the phenotypic expression of NAFLD, including hepatic steatosis and hepatic fibrosis (identified using vibration controlled transient elastography and controlled attenuation parameter measured by the FibroScan Device). We screened for depression using the Beck Depression Inventory-II (BDI-II). We identified significant G × E interactions for hepatic fibrosis × BDI-II. These findings provide evidence that genetic factors interact with depression to influence the expression of hepatic fibrosis.

Engineered Dutasteride-Lipid Based Nanoparticle (DST-LNP) System Using Oleic and Stearic Acid for Topical Delivery

Male pattern baldness (MPB) is a common condition that has a negative impact on the psycho-social health of many men. This study aims to engineer an alcohol-free formulation to cater for individuals who may have had allergic reactions to alcohol-based preparations. A lipid-based nanoparticle system composed of stearic and oleic acid (solid and liquid lipid) was used to deliver dutasteride (DST) for topical application. Two compositions, with oleic acid (Formulation A) and without (Formulation B), were compared to analyse the role of oleic acid as a potential active ingredient in addition to DST. DST-loaded LNP were prepared using the emulsification–ultrasonication method. All of the prepared formulations were spherical in shape in the nanometric size range (150–300 nm), with entrapment efficiencies of >75%. X-ray diffractograms revealed that DST exists in an amorphous form within the NLP matrices. The drug release behaviour from both LNP preparations displayed slow release of DST. Permeation studies through pig ear skin demonstrated that DST-LNP with oleic acid produced significantly lower permeation into the dermis compared to the formulation without oleic acid. These results suggest that the proposed formulation presents several characteristics which are novel, indicating its suitability for the dermal delivery of anti-androgenic molecules.

In Vitro Performance of Dutasteride-Nanostructured Lipid Carriers Coated with Lauric Acid-Chitosan Oligomer for Dermal Delivery

Dutasteride, licensed as an oral medicine for the treatment of benign prostatic hypoplasia, has been investigated as a treatment for androgenic alopecia. In this study, the potential for dustasteride to be delivered topically in order to reduce systemic exposure, irritation of the skin, and also cytotoxicity was explored. Chitosan oligomer (CSO) was successfully synthesised with lauric acid as a coating for a dutasteride-loaded nanostructured lipid carriers (DST-NLCs) system. DST-NLCs were prepared using a combination of melt-dispersion and ultrasonication. These negatively charged NLCs (-18.0 mV) had a mean particle size of ~184 nm, which was not significantly increased (p > 0.05) when coated with lauric acid-chitosan oligomer (CSO-LA), whilst the surface charge changed to positive (+24.8 mV). The entrapment efficiency of DST-NLCs was 97%, and coated and uncoated preparations were physically stable for up to 180 days at 4-8 °C. The drug release was slower from DST-NLCs coated with CSO-LA than from uncoated NLCs, with no detectable drug permeation through full-thickness pig ear skin from either preparation. Considering the cytotoxicity, the IC50 values for the DST-NLCs, coated and uncoated with CSO-LA were greater than for dutasteride alone (p < 0.05). DST-NLCs and empty NLCs coated with CSO-LA at 25 µM increased the cell proliferation compared to the control, and no skin irritation was observed when the DST-NLC formulations were tested using EpiDerm™. The cell and skin uptake studies of coated and uncoated NLCs incorporating the fluorescent marker Coumarin-6 showed the time-dependent uptake of Coumarin-6. Overall, the findings suggest that DST-NLCs coated with CSO-LA represent a promising formulation strategy for dutasteride delivery for the treatment of androgenic alopecia, with a reduced cytotoxicity compared to that of the drug alone and lower irritancy than an ethanolic solution of dutasteride.

Diabetes Device Use and Glycemic Control among Youth with Type 1 Diabetes: A Single-Center, Cross-Sectional Study

AIM

The purpose of this cross-sectional study was to determine the rates of diabetes device use (insulin pump and continuous glucose monitor (CGM)) and association with glycemic control in youth with type 1 diabetes in a large, diverse pediatric center.

METHODS

Demographic and clinical data were obtained from 1992 patients who met the eligibility criteria (age < 26 years, diabetes duration ≥ 1 year, and ≥1 clinic visit in the preceding 12 months). Statistical analyses assessed the likelihood of device use based on demographic characteristics and the association between device use and glycemic control based on most recent hemoglobin A1c (HbA1c).

RESULTS

Mean age was 13.8 ± 4.2 years, 50.7% were female, diabetes duration was 6.2 ± 4 years, and mean HbA1c was 8.7 ± 1.8%. Overall, 38.2% of patients were on pump therapy and 18.5% were on CGM. Patients who were non-Hispanic (NH) white, privately insured, and with primary English-speaking parent(s) had higher rates of insulin pump use, as well as CGM use (P < 0.001 for both). Female patients had higher rates of pump use only (P < 0.01). Private health insurance, NH white race/ethnicity, and CGM use were each associated with lower HbA1c (P = 0.03, <0.001, and <0.008, resp.).

CONCLUSION

At a large, diverse, pediatric diabetes center, disparities in diabetes device use were present across sex, race/ethnicity, health insurance coverage, and primary language of parent(s). CGM use was associated with lower HbA1c. Quality improvement efforts are underway to ensure improved access, education, and clinical programs for advanced diabetes devices for T1D patients.

Anatomical pulmonary magnetic resonance imaging segmentation for regional structure-function measurements of asthma

PURPOSE

Pulmonary magnetic-resonance-imaging (MRI) and x-ray computed-tomography have provided strong evidence of spatially and temporally persistent lung structure-function abnormalities in asthmatics. This has generated a shift in their understanding of lung disease and supports the use of imaging biomarkers as intermediate endpoints of asthma severity and control. In particular, pulmonary (1)H MRI can be used to provide quantitative lung structure-function measurements longitudinally and in response to treatment. However, to translate such biomarkers of asthma, robust methods are required to segment the lung from pulmonary (1)H MRI. Therefore, their objective was to develop a pulmonary (1)H MRI segmentation algorithm to provide regional measurements with the precision and speed required to support clinical studies.

METHODS

The authors developed a method to segment the left and right lung from (1)H MRI acquired in 20 asthmatics including five well-controlled and 15 severe poorly controlled participants who provided written informed consent to a study protocol approved by Health Canada. Same-day spirometry and plethysmography measurements of lung function and volume were acquired as well as (1)H MRI using a whole-body radiofrequency coil and fast spoiled gradient-recalled echo sequence at a fixed lung volume (functional residual capacity + 1 l). We incorporated the left-to-right lung volume proportion prior based on the Potts model and derived a volume-proportion preserved Potts model, which was approximated through convex relaxation and further represented by a dual volume-proportion preserved max-flow model. The max-flow model led to a linear problem with convex and linear equality constraints that implicitly encoded the proportion prior. To implement the algorithm, (1)H MRI was resampled into ∼3 × 3 × 3 mm(3) isotropic voxel space. Two observers placed seeds on each lung and on the background of 20 pulmonary (1)H MR images in a randomized dataset, on five occasions, five consecutive days in a row. Segmentation accuracy was evaluated using the Dice-similarity-coefficient (DSC) of the segmented thoracic cavity with comparison to five-rounds of manual segmentation by an expert observer. The authors also evaluated the root-mean-squared-error (RMSE) of the Euclidean distance between lung surfaces, the absolute, and percent volume error. Reproducibility was measured using the coefficient of variation (CoV) and intraclass correlation coefficient (ICC) for two observers who repeated segmentation measurements five-times.

RESULTS

For five well-controlled asthmatics, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) was 83% ± 7% and FEV1 was 86 ± 9%pred. For 15 severe, poorly controlled asthmatics, FEV1/FV C = 66% ± 17% and FEV1 = 72 ± 27%pred. The DSC for algorithm and manual segmentation was 91% ± 3%, 92% ± 2% and 91% ± 2% for the left, right, and whole lung, respectively. RMSE was 4.0 ± 1.0 mm for each of the left, right, and whole lung. The absolute (percent) volume errors were 0.1 l (∼6%) for each of right and left lung and ∼0.2 l (∼6%) for whole lung. Intra- and inter-CoV (ICC) were <0.5% (>0.91%) for DSC and <4.5% (>0.93%) for RMSE. While segmentation required 10 s including ∼6 s for user interaction, the smallest detectable difference was 0.24 l for algorithm measurements which was similar to manual measurements.

CONCLUSIONS

This lung segmentation approach provided the necessary and sufficient precision and accuracy required for research and clinical studies.

Methods and Problems of a Stroke Rehabilitation Trial

There are conflicting views on the effectiveness of rehabilitation after stroke; several studies have attempted to compare progress following intensive therapy with that following community care1–6 or no formal treatment,7–9 but for a number of reasons the evidence is inconclusive. Consequently, we have been engaged in a randomised controlled trial of the effectiveness of different intensities of out-patient rehabilitation following stroke. This paper outlines the design, methods and problems of the study.

Experiences and meanings of integration of TCAM (Traditional, Complementary and Alternative Medical) providers in three Indian states: results from a cross-sectional, qualitative implementation research study

OBJECTIVES

Efforts to engage Traditional, Complementary and Alternative Medical (TCAM) practitioners in the public health workforce have growing relevance for India's path to universal health coverage. We used an action-centred framework to understand how policy prescriptions related to integration were being implemented in three distinct Indian states.

SETTING

Health departments and district-level primary care facilities in the states of Kerala, Meghalaya and Delhi.

PARTICIPANTS

In each state, two or three districts were chosen that represented a variation in accessibility and distribution across TCAM providers (eg, small or large proportions of local health practitioners, Homoeopaths, Ayurvedic and/or Unani practitioners). Per district, two blocks or geographical units were selected. TCAM and allopathic practitioners, administrators and representatives of the community at the district and state levels were chosen based on publicly available records from state and municipal authorities. A total of 196 interviews were carried out: 74 in Kerala, and 61 each in Delhi and Meghalaya.

PRIMARY AND SECONDARY OUTCOME MEASURES

We sought to understand experiences and meanings associated with integration across stakeholders, as well as barriers and facilitators to implementing policies related to integration of Traditional, Complementary and Alternative (TCA) providers at the systems level.

RESULTS

We found that individual and interpersonal attributes tended to facilitate integration, while system features and processes tended to hinder it. Collegiality, recognition of stature, as well as exercise of individual personal initiative among TCA practitioners and of personal experience of TCAM among allopaths enabled integration. The system, on the other hand, was characterised by the fragmentation of jurisdiction and facilities, intersystem isolation, lack of trust in and awareness of TCA systems, and inadequate infrastructure and resources for TCA service delivery.

CONCLUSIONS

State-tailored strategies that routinise interaction, reward individual and system-level individual integrative efforts, and are fostered by high-level political will are recommended.

Engineering hydrophobically modified chitosan for enhancing the dispersion of respirable microparticles of levofloxacin

The potential of amphiphilic chitosan formed by grafting octanoyl chains on the chitosan backbone for pulmonary delivery of levofloxacin has been studied. The success of polymer synthesis was confirmed using FT-IR and NMR, whilst antimicrobial activity was assessed against Pseudomonas aeruginosa. Highly dispersible dry powders for delivery as aerosols were prepared with different amounts of chitosan and octanoyl chitosan to study the effect of hydrophobic modification and varying concentration of polymer on aerosolization of drug. Powders were prepared by spray-drying from an aqueous solution containing levofloxacin and chitosan/amphiphilic octanoyl chitosan. l-leucine was also used to assess its effect on aerosolization. Following spray-drying, the resultant powders were characterized using scanning electron microscopy, laser diffraction, dynamic light scattering, HPLC, differential scanning calorimetry, thermogravimetric analysis and X-ray powder diffraction. The in vitro aerosolization profile was determined using a Next Generation Impactor, whilst in vitro antimicrobial assessment was performed using MIC assay. Microparticles of chitosan have the property of mucoadhesion leading to potential increased residence time in the pulmonary mucus, making it important to test the toxicity of these formulations. In-vitro cytotoxicity evaluation using MTT assay was performed on A549 cell line to determine the toxicity of formulations and hence feasibility of use. The MTT assay confirmed that the polymers and the formulations were non-cytotoxic. Hydrophobically modifying chitosan showed significantly lower MIC (4-fold) than the commercial chitosan against P. aeruginosa. The powders generated were of suitable aerodynamic size for inhalation having a mass median aerodynamic diameter less than 4.5μm for formulations containing octanoyl chitosan. These highly dispersible powders have minimal moisture adsorption and hence an emitted dose of more than 90% and a fine particle fraction (FPF) of 52%. Powders with non-modified chitosan showed lower dispersibility, with an emitted dose of 72% and FPF of 20%, as a result of high moisture adsorption onto the chitosan matrix leading to cohesiveness and subsequently decreased dispersibility.

Colorectal cancer detection: time to abandon barium enema?

OBJECTIVES

To assess the sensitivity of double contrast barium enema (DCBE) for diagnosing colorectal cancer (CRC).

DESIGN

Retrospective evaluation of DCBE performed in the 2 years prior to diagnosis of CRC.

SETTING

Teaching hospital in Cambridge, UK.

PATIENTS

1310 consecutive cases of CRC identified from cancer registry data.

INTERVENTIONS

DCBE and colonoscopy.

MAIN OUTCOME MEASURES

Sensitivity of DCBE for diagnosing CRC.

RESULTS

215 patients had undergone a DCBE within the 2 years prior to diagnosis with CRC. After excluding those reported as inadequate, 37 of these were reported as normal, giving a sensitivity of 83% (81-85%).

CONCLUSIONS

The performance of DCBE is inadequate for the exclusion of CRC. Expansion of colonoscopy and CT colonography capacity is urgently required nationally so that DCBE can finally be abandoned as a firstline test in patients at risk of CRC.

Undergraduate medical education in the Gulf Cooperation Council: a multi-countries study (Part 1)

BACKGROUND

The Gulf Cooperation Council (GCC) countries have witnessed over the last 40 years a rapid and major social, cultural, and economic transformation. The development of medical education in the region is relatively new, dating from the late 1960s. An important goal among the medical colleges in the region is to graduate national physicians who can populate the healthcare service of each country.

AIM

The aim of this study is to provide understanding of undergraduate medical education in each of the six GCC countries and the challenges that each face.

METHODS

This is a descriptive cross-sectional study. Fourteen senior medical faculty were requested to submit information about undergraduate medical education in their own countries, focusing on its historical background, student selection, curriculum, faculty, and challenges.

RESULTS

The information provided was about 27 medical colleges: 16 from the Kingdom of Saudi Arabia (KSA), five from the United Arab Emirates (UAE), two from the Kingdom of Bahrain, two from Sultanate of Oman, one from Kuwait, and one from the State of Qatar. It was found that older colleges are reviewing their curriculum while new colleges are developing their programs following current trends in medical education, particularly problem-based learning and integrated curricula. The programs as described 'on paper' look good but what needs to be evaluated is the curriculum 'in action'. Faculty development in medical education is taking place in most of the region's medical colleges.

CONCLUSION

The challenges reported were mainly related to shortages of faculty, availability of clinical training facilities and the need to more integration with the National Health Care services. Attention to quality, standards, and accreditation is considered essential by all colleges.

Utility of provider volume as an indicator of medical care quality and for policy decisions

Associations between hospital volume or physician caseload and patient outcome have been used to assess the performance of health care providers. Although most studies have focused on major surgical procedures, in-hospital or 30-day mortality from many nonsurgical conditions and procedures has also been examined. Although high volume may be a surrogate for the provider's skill and experience, and better outcomes may attract greater volumes, aggregate data on provider volume show many outliers indicating that the outcome for some low-volume providers is better than that for high-volume providers. Mortality is only one measure of medical care quality. Although high volume may not always be indicative of favorable outcome, referral of patients from low-volume to high-volume providers has been recommended. It has also been suggested that patients choose health care providers on the basis of physician caseload. It is unclear how such recommendations could be implemented in practice; furthermore, they would deprive many patients from access to, as well as disrupt the provision of, adequate health care in many areas. An alternative to requiring patients to receive care from high-volume providers is to adopt other measures for improving outcomes, such as improving the quality of care provided by low-volume providers and attracting better providers to low-volume areas.

Urban-rural differences in the quality of care for medicare patients with acute myocardial infarction

BACKGROUND

There are urban-rural differences in health care utilization in Kansas. This study was conducted to determine if similar differences exist in the quality of inpatient care provided for patients with acute myocardial infarction (AMI).

METHODS

All acute care hospitals in the state were stratified into 12 urban, 31 semirural, and 76 rural hospitals according to their location. Data from medical records of 2521 Medicare patients 65 years and older who had survived AMI and were discharged alive from hospitals during an 8-month period in 1994/1995 were abstracted. The measures of the quality of care (quality indicators [QIs]) were the use of aspirin (during hospital stay and at discharge) and the administration of beta-blockers, intravenous (IV) nitroglycerin, heparin, and reperfusion by thrombolytic therapy or primary angioplasty.

RESULTS

A significantly higher proportion of ideal candidates for the use of aspirin during hospital stay and at discharge, heparin, and IV nitroglycerin received these medications in urban hospitals, and a lower proportion of similar patients received these medications in rural hospitals compared with the patients in semirural hospitals (P<.001). Similar trends in each of the 6 QIs were observed for less than ideal patients (P<.05). Patient age was associated with a relatively poor quality of care in terms of the 6 QIs. Except for the administration of IV nitroglycerine to less than ideal patients, age adjustments did not change the observed urban-rural differences in the QI measures.

CONCLUSION

Relatively poor quality of care for patients with AMI was provided by rural hospitals where greater opportunity for improvement exists.