High prevalence of adrenal suppression during acute illness in hospitalized patients receiving megestrol acetate.

INTRODUCTION: Megestrol acetate (MA) is a progestational agent used for palliation of breast and endometrial cancer. The drug promotes weight gain via appetite stimulation. This property has led to widespread use in patients with wasting illnesses. Increasing numbers of reports suggest glucocorticoid activity. OBJECTIVE: Unrecognized adrenal suppression may result from MA use. This is the first study to examine the prevalence of adrenal suppression in hospitalized patients treated with MA. SUBJECTS AND DESIGN: This is a cross-sectional study of hospitalized patients receiving MA compared to control subjects. Morning cortisol levels, endocrine signs and symptoms, and duration of MA therapy were evaluated in 28 hospitalized medical patients treated with MA, and 21 control patients admitted to the same hospital service during the study period. RESULTS: Median cortisol levels were significantly lower in patients using MA vs controls (160 vs 386 nmol/l, p=0.003). Forty-three percent of subjects on MA demonstrated morning cortisol levels below the normal range (138-690 nmol/l), compared with 10% of controls (p=0.013). Ninety-three percent of subjects taking MA had morning cortisol levels below the level that excludes adrenal insufficiency in hospitalized patients (497 nmol/l) vs 71% of controls (p=0.06). CONCLUSIONS: MA use is associated with significant adrenal suppression in acutely ill individuals. This should alert physicians to the possibility of adrenal insufficiency and the need to assess for signs or symptoms of adrenal insufficiency, and mandates a low threshold for testing adrenal function in hospitalized patients taking MA.

Who will lead?

A recent survey conducted by the UCLA Center for Health Services Management and the Physician Executive Practice of Heidrick & Struggles, an executive search firm, sheds light on the emerging physician executive's role. The goal of the research was to identify success factors as a means of evaluating and developing effective industry leaders. Respondents were asked to look at specific skills in relation to nine categories: Communication, leadership, interpersonal skills, self-motivation/management, organizational knowledge, organizational strategy, administrative skills, and thinking. Communication, leadership, and self-motivation/management emerged, in that order, as the three most important success factors for physician executives. An individual's general competencies, work styles, and ability to lead others through organizational restructuring defines his or her appropriateness for managerial positions in the health care industry.

Strategies for achieving sustained competitive advantage.

Sound strategic planning, even in the midst of unprecedented uncertainty and turmoil, is a critical element of every successful health care organization's action plan. The author examines how one organization has responded to the changing demands of the marketplace and a dramatically changed reimbursement system through appropriate strategic planning, selective downsizing on certain fronts and new product development expansion on others. The result is an organization molded to the new environment. It is no longer based on an illness-model hospital but rather focuses on a vertically integrated multi-health cluster intent on capturing market share by providing a single source continuum of health care.