Medical Health

Legislation to reauthorize the Substance Abuse and Mental Health Services Administration should provide states with more flexibility in the use of grants awarded by the agency to improve substance abuse and mental health treatment, witnesses testified on Thursday at a Senate Health, Education, Labor and Pensions Committee hearing, CQ HealthBeat reports. Sen. Richard Burr (R-N.C.) said, "Everybody’s problem is a little bit unique."

In addition, witnesses testified that grants awarded by SAMHSA should do more to coordinate local treatment services into comprehensive treatment programs for patients with substance abuse problems, mental illnesses or both. Rep. Patrick Kennedy (D-R.I.) said that legislation to reauthorize SAMHSA should seek to coordinate the "fragmented" mental health care system, which undermines treatment for such patients, and establish a permanent commission that would provide information on "evidence-based practices" to ensure patients are "getting the latest and best treatment." Terry Allebaugh — executive director of Housing for New Hope, a program for homeless residents in Durham, N.C. — added that "piecemeal services and spare change do not lead to transformative care."

Rodger McDaniel, deputy director of the Wyoming Department of Health, cited the need for a focus on "brain science" in grants awarded by SAMHSA. Lisa Halpern, who testified on behalf of the National Alliance on Mental Illness, said that legislation to reauthorize the agency should seek to promote effective treatment programs for severe mental illnesses. SAMHSA Administrator Terry Cline said states that currently receive grants from the agency have made progress in the development of systems to determine which treatment programs are most effective, adding, "We’re not there yet, but we’re on the way" (Reichard, CQ HealthBeat, 5/8).

Employees who participated in a worksite health program improved blood pressure control by 9 percent and diabetes control by 15 percent, researchers reported at the American Heart Association’s 8th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.

During three years (2004-06) of follow-up on 2,100 workers, researchers also found that absenteeism declined significantly at JEA, a municipal utility in Jacksonville, Fla. The number of employees who missed work due to hypertension dropped from 25.8 percent to 15.6 percent, while those who missed work because of diabetes dropped by 66.2 percent (from 50 percent to 16.9 percent).

Workplace accidents also dropped by nearly 70 percent from 83 incidents in 2003 to 25 incidents in 2006. In all, 20 of the 83 incidents in 2003 resulted in lost time away from work, compared to only seven incidents in 2006.

The rising cost of medical care and the utility’s predominantly male workforce (median age, 47) contributed to the need for a program that focused on preventing heart and blood vessel disease, said Sharon A. Clark, D.H.Sc., lead author of the study and JEA’s health promotion specialist.

"With an aging workforce, we were concerned with making a change to the modifiable risk factors for cardiovascular disease for our employees," Clark said.

While safety has long been a priority at the utility, about a dozen employees started the worksite health program in 1989. The workers had been walking along the bridges in Jacksonville’s downtown river area during their lunch hours and decided they wanted a more formal exercise facility, Clark said.

"They approached the company to create a fitness center," she said. "Being a public utility, JEA has to be mindful of where its resources are spent."

The company agreed to provide the space, custodial help and security services, and the employees took out a loan for the equipment. The employees also chose the exercise classes and took over most of the day-to-day administration of what has expanded into seven fitness centers at various company facilities.

"Over the years, the company began to notice benefits to helping workers stay fit," Clark said. "The program has grown to where it is now part of the company’s strategic plan."

For the study, JEA teamed up with its healthcare provider, Blue Cross/Blue Shield of Florida and with Pfizer Global Pharmaceuticals in Jacksonville.

With their help, the company expanded its safety and health program into a comprehensive wellness system that includes live and written health education information, health screenings, coaching and an incentive program to encourage participation.

Researchers, collecting mounds of data during the three years of follow-up, attempted to quantify the effects of lifestyle-changing activities aimed at reducing cardiovascular disease risks such as smoking, excess weight, high blood pressure and diabetes.

The backbone of the program is the Health Risk Assessment (HRA), a screening tool that includes measures of employees’ health through blood pressure, blood sugar and cholesterol testing. It also includes a 60-question survey that asks about current health status, family history, daily nutrition, physical activity, the use of alcohol and tobacco, safe habits (such as seat belt usage), stress and depression, use of available medical screening tests and gender-related health questions.

The survey ends by asking questions that measure how willing an employee is to make lifestyle changes related to health and safety, and providing coaching to accomplish that change.

"Just knowing about something doesn’t make you change," Clark said. "So the last part of the HRA is one-on-one coaching."

Employees are asked what they want to change first, such as weight, blood pressure or diabetes control. The coaching, set up through the health insurance company, is structured so that patients can call the same coach repeatedly to build a dialogue.

The researchers also used a Wellness Inventory Survey (WIS) to gather data and provided incentives such as time off or the chance to win prizes for participating in the survey and other aspects of the health and safety program.

The survey includes questions about absenteeism (time away from work due to illness) and presenteeism (unproductive time spent at work due to health or personal situations that make it hard to concentrate). During the study, the percentage of employees with normal blood pressure increased from 28 percent to 37 percent and the percentage with normal blood glucose (sugar) increased from 43 percent to 58 percent. The percentage of non-smokers increased from 86 percent to 89 percent.

Employees also reported feeling better about themselves, with a significant increase in the percentage describing their health status as "excellent or very good," jumping 22 percent from 41.7 percent to nearly 51 percent.

"We are planning to continue to work with modifiable risk factors because we think it benefits both the employees and the employer," Clark said.

The Healthcare Commission has completed an independent review process of the 2006 performance ratings for NHS trusts in England.

Of the 570 NHS trusts assessed by the Commission last year, 17 trusts requested a review of their rating - less than 3% of trusts. Two requests were upheld:

A panel including senior staff from the Healthcare Commission, as well as independent experts from the Audit Commission and the Commission for Social Care Inspection, reviewed six of the requests. A team within the Healthcare Commission reviewed the remaining 11 requests.

The Healthcare Commission has taken on board advice from the healthcare sector that it should focus on whether a trust has complied with a core standard overall, not necessarily every single component in every single circumstance. In both of the requests upheld, the Commission agreed that although there were lapses, the trusts had met the standard overall.

– The University Hospitals Coventry and Warwickshire NHS Trust requested a review of the Commission’s assessment of core standard C15a: "Where food is provided, healthcare organisations have systems in place to ensure that patients are provided with a choice and that it is prepared safely and provides a balanced diet." The Commission found that while the Trust was not compliant with criteria relating to choice of food, these lapses were insufficient to say that the Trust had not met the standard overall. As a result, the Trust is now considered to have met all of the core standards and its score for quality of services has been changed from "good" to "excellent". The Trust’s score for use of resources remains "fair".

– Bassetlaw Primary Care Trust requested a review of the Commission’s assessment of core standard C4c: "All reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed." The Commission concluded that, despite some identified lapses, they were not significant lapses and the request for review was upheld. This had no effect on the Trust’s final rating, which remains at "good" but it is now considered to have met all of the core standards.

Gary Needle, Head of NHS Assessment at the Healthcare Commission, said: "The annual health check is a very thorough and comprehensive assessment of trusts’ performance. We had very few requests for review, but nonetheless, it’s important that trusts have the opportunity to question decisions made by the Healthcare Commission in an open and fair manner.

"I’m very pleased that University Hospitals Coventry and Warwickshire NHS Trust is now one of the few trusts to receive a score of ‘excellent’ for quality of services in last year’s annual performance ratings."

As part of the review process, the Commission automatically checks the ratings of all trusts to determine if any are affected by a decision, regardless of whether they have requested a review. In this case, the Commission changed its assessments of core standard C15a for Buckinghamshire Hospitals NHS Trust and Plymouth Hospitals NHS Trust. These amendments did not affect trusts’ final ratings, however Plymouth Hospitals NHS Trust is now considered to have ‘almost met’ the core standards.

– Annual health check requests for review page

Information on the Healthcare Commission

The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

www.healthcarecommission.org.uk

The results of the 2006 National Sentinel Audit for Stroke show that patients are spending more of their time on stroke units, but there are still unacceptable waits for brain scans and starting treatment. Results from Wales are still falling behind those from England, and are a major cause for concern. A separate release on the Welsh results is available.

The Audit, funded by the Healthcare Commission, was carried out on behalf of the Intercollegiate Stroke Group by the Royal College of Physicians’ Clinical Effectiveness and Evaluation Unit (CEEu), and covers 100% of eligible hospitals in England and Wales. As in 2005, results for each participating site are published on the RCP website:

– Royal College of Physicians
– National Sentinel Stroke Audit report (pdf 436kb)

Headline results:

– 62% of patients were admitted to a stroke unit at some point in their stay, compared to 46% in 2004. 54% spent over half their stay in a stroke unit (40% in 2004). This is a significant and welcome improvement, as now 91% of hospitals have a stroke unit (79% in 2004) but there is still a lack of capacity

– The most dramatic rise in stroke units was in England, which improved from 82% in 2004 to 97% in 2006, while in Wales the number of stroke units is 9 (45%), the same as in 2004

– Patients managed on stroke units have much better results than patients looked after in other settings �" they are much more likely to have had their ability to swallow checked, to have started aspirin within 48 hours, been assessed by therapists within the recommended times; had rehabilitation goals documented and have a home visit performed before discharge

– 76% of patients with minor stroke in hospital for less than 2 days are not being managed on specialist units. These patients have a high risk of having another stroke and should receive expert care and investigation

– Mean length of stay has fallen considerably over the last two cycles of audit from 27.9 days in 2004 and 34 days in 2001, to 25.4 days in 2006. These shorter lengths of stay are not due to patients being moved too early into care homes, as the audit measures transfer to care homes separately and there is no change from the 2004 figure of 13%.

– The proportion of patients with mild stroke has fallen from 29% in the 2004 audit to 24% in 2006, suggesting that such patients are being discharged earlier without the opportunity to complete their rehabilitation �" this is worrying as there has been no significant increase in specialist community rehabilitation teams

– Early access to a stroke unit has improved since 2004, but only 15% of patients are admitted to a stroke unit on the same day and only 12% of patients are being admitted directly to a stroke unit (within 4 hours of arrival at hospital)

– Only 42% of patients had brain imaging to confirm their diagnosis within 24 hours of the onset of symptoms. This figure is unacceptably low and must be improved. Patients need a brain scan to determine if it is appropriate to prescribe aspirin �" if given within 48 hours of the stroke this can save lives and reduce disability

– Only 9% of patients were scanned within 3 hours of stroke �" if not scanned on the day of admission, they normally have to wait until the next working day - this is a particular problem if admitted at the weekend as very few scans are performed outside the hours of 8.00 am-6.00 pm

– Problems remain with stroke patients getting access to therapists and social workers �" a third of patients who have difficulty swallowing have not been assessed by a Speech and Language Therapist within 72 hours of admission or within 7 days for those having difficulty communicating. The situation is similar for physiotherapy and for occupational therapy and social work it is even worse

– Assessment of carer needs is one of the areas of practice that has improved most since the last audit, from 43% to 68%, but there has been no improvement in discussing the diagnosis and likely progress with patients

Hypertension is a serious condition affecting millions. Currently there are seven classes of drugs used to reduce blood pressure. Aliskiren (Tekturna®, Rasilez®) is the first of a new class of orally active antihypertensive drugs that works by inhibiting renin. A review of six large-scale clinical trials of aliskiren is being published in the May issue of the American Journal of Hypertension. The authors report that, because of reactive renin secretion, this drug has not been any more effective than those already widely available to control hypertension.

Renin inhibitors, for which aliskiren is a prototype, become the fourth class of drugs to lower blood pressure by blocking the renin-angiotensin system. Previously existing classes are beta blockers, converting enzyme inhibitors (CEIs) and angiotensin receptor blockers (ARBs). Many drugs in these classes have lost patent protection and are available as generics.

In analyzing clinical trials involving over 5000 hypertensive patients, aliskiren was not more effective as an antihypertensive agent than CEIs, ARBs or diuretics and it has a limited antihypertensive dose response curve. Although aliskiren lowered blood pressure to a greater extent when combined with a CEI or an ARB or a diuretic, blood pressure control was achieved by less than 50% of patients. Because aliskiren stimulates kidney renin secretion to a greater degree than do CEIs or ARBs, its antihypertensive capabilities can be counteracted by large reactive increases in renin secretion; this is particularly likely at higher dosage.

The Wall Street Journal on Thursday examined documents provided by Dean McClellan, a former sales agent for Johnson & Johnson’s Ortho Biotech unit, who has joined a whistleblower lawsuit alleging that the company offered excessive financial incentives for doctors to prescribe anemia drug Procrit and encouraged doctors to prescribe higher-than-approved doses (Won Tesoriero/Johnson, Wall Street Journal, 5/10).

Federal law prohibits pharmaceutical companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients at pharmacies, but companies can rebate part of the price to doctors who purchase treatments that are administered in their offices. Anemia drugs are injected or delivered intravenously in doctors’ offices or dialysis centers (Kaiser Daily Health Policy Report, 5/9).

McClellan, who says he was forced to retire in 2004 because of age discrimination, saved 15,000 pages of company memos, contracts and other documents. The documents show that after Amgen’s competing anemia drug Aranesp was introduced in 2004, Ortho offered new discounts to health care providers who purchased Procrit, even when they already were buying the drug at a reduced price and were receiving rebates.

One memo calculated that under the program, a physician who purchased nearly $1 million of Procrit over 15 months would receive a check for $237,885, the Journal reports. A separate program offered hospitals discounts across J&J’s product line if they used Procrit at least 75% of the time when prescribing anemia drugs. In addition, Ortho created a "Right of First Refusal" contract requiring doctors to allow J&J to make a counteroffer if Amgen’s price for Aranesp was lower than the Procrit price.

In his suit, McClellan also alleges that Ortho in the mid-1990s began encouraging doctors to prescribe a high dose of Procrit that was not FDA-approved. McClellan said that Ortho offered no-cost "trial" samples of Procrit to doctors who agreed to try the higher dose (Wall Street Journal, 5/10).

Broadcast Coverage
American Public Media’s "Marketplace" on Wednesday reported on anemia drugs. The segment includes comments from Eric Winer, director of the Breast Oncology Center at the Dana-Farber Cancer Institute, and Max Jacobs, an analyst at Mehta Partners (Palmer, "Marketplace," American Public Media, 5/9). Audio and a transcript of the segment are available online.

A simple procedural change may significantly reduce cardiopulmonary arrests outside a pediatric hospital’s intensive care unit, according to a study reported at the American Heart Association’s 8th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.

Cardiac arrests outside the Pediatric Intensive Care Unit (PICU) at Children’s Medical Center Dallas dropped by 63 percent after doctors and nurses changed procedures to call the cardiac emergency team or Code Blue Team, whenever warning signs indicated a patient’s lungs or heart might stop working. Previously, staff summoned the team only after starting cardiopulmonary resuscitation (CPR) after a cardiac arrest.

"Our goal was to get patients moved to the PICU and a higher level of care sooner, hoping to prevent an arrest," said Tia A. Tortoriello, M.D., senior author of the study, assistant professor of pediatrics in the Division of Cardiology at University of Texas Southwestern Medical Center at Dallas and medical staff member at Children’s Medical Center Dallas. "And if we couldn’t prevent it, the arrest could be better controlled in the PICU."

Cardiac arrest is different in children than in adults. In adults, heart stoppages mostly result from a heart attack or electric malfunction of the heart. Children rarely have a primary cardiac arrest. Most often, their arrests evolve from respiratory problems, researchers said.

Tortoriello joined the 411-bed hospital’s CPR Committee as co-chair in late 2003. She became convinced that the data it had collected could lead to better ways to reduce the number of patients who suffered a full cardiac arrest outside the PICU.

Tortoriello credits the American Heart Association’s National Registry of Cardiopulmonary Resuscitation (NRCPR) with enabling Children’s Medical Center to shift its response focus from reaction and resuscitation to earlier intervention and prevention.

The registry collects data from many member hospitals, which allows individual institutions to compare their rates of cardiopulmonary arrests and resuscitations with hospitals of similar size and types of patients. They can also evaluate their Code Blue Team’s methods to determine how to improve them.

Tortoriello and her team found that the hospital’s cardiac "hotspot" - the non-critical care area where a cardiopulmonary arrest was most likely to occur - was the chronic vent floor, where patients are maintained on ventilators.

"Patients may acutely plug their tracheostomy or have significantly increased respiratory issues," she said. Either may cause "a respiratory arrest that can progress to a cardiac arrest." After analyzing data and obtaining hospital approval, the CPR Committee made a symbolic change. It renamed the Code Blue Team to the Pediatric Advanced Life Support (PALS) Team. Team members and their duties remained the same.

"The substantive revision of when to call for the PALS Team was harder to implement," Tortoriello said. "It was difficult to get people to change their mindset from waiting to call for help until the patient had arrested to calling at their earliest concern for the patient."

During the first three months of 2005, she and her colleagues instructed hospital staff about the early warning signs of a potential cardiopulmonary arrest in children. These include increased respiratory rate, labored breathing, increased oxygen use, excessive sleepiness and irritability.

They later compared data gathered from October 2003 through March 2005, and from April 2005 through November 2006. They found some positive results - and one that puzzled them:

* The number of cardiopulmonary arrests outside the PICU dropped from 68 over a total of 237 events to 30 over a total of 274 events.

* Arrests in noncritical-care areas declined from 2.7 arrests to 1 arrest per 1,000 patients discharged, a decrease of 63 percent.

* Patients needing escalation of care - those who had not suffered an arrest but whose distressed condition benefited from the expertise of the PALS Team - increased from 3.0 patients per month in the first period to 3.4 per month in the second timeframe. That difference was not statistically significant.

* The PICU mortality rate dropped from 4.5 percent in the first period to 4.4 percent in the second, a difference not statistically significant.

The researchers did not track what happened specifically to patients arriving earlier at the PICU under its new system. However, the stability of the PICU death rate surprised them.

"If you recognize these patients sooner, get them to the PICU, and intervene before something bad happens, you would expect to see a decrease in our PICU mortality rate," Tortoriello said. "However, a change in the hospital’s status might explain the finding, at least in part."

During the study, Children’s Medical Center Dallas was designated a Level 1 pediatric trauma center - the only one in Texas. Level 1 means a hospital meets strict national standards for the quality of its care in a specific area of medicine. "It may be that we are now seeing more children and sicker children in our PICU," Tortoriello said. She and her colleagues continue to monitor the cardiac arrest data, seeking better ways to improve preventive care.

"It’s still a work in progress," Tortoriello said. "The goal is to not have a single arrest outside of the PICU."

Enactment of the Geriatric Assessment and Chronic Care Coordination Act of 2007 (S. 1340) will represent a marked departure from Medicare’s practice of paying physicians only for episodic and acute care, the Senate Special Committee on Aging was told today by the American College of Physicians (ACP) in a statement submitted for the record. During its hearing on The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Senators were told about the advantages of realigning benefits and payment incentives to support a comprehensive geriatric assessment.

"Ongoing care coordination for patients with multiple chronic diseases and/or dementia is critical," said ACP President David C. Dale, MD, FACP. "It is essential that the system incorporate several of the key elements of the Patient-Centered Medical Home."

ACP, which represents 120,000 physicians and medical students, is the largest medical specialty society and the second largest medical organization in the United States. Internists provide care for more Medicare patients than any other medical specialty.

ACP strongly believes that Medicare and other health plans should be reformed to advance the Patient-Centered Medical Home, a model of health-care delivery that has been proven to result in better quality, more efficient use of resources, reduced utilization, and higher patient satisfaction. Congress should also authorize a new Medicare benefit for geriatric assessments of patients with multiple chronic diseases and/or dementia and payment of a care coordination fee to physicians who accept responsibility for such patients.

The Patient-Centered Medical Home: A Model for Improving Care Coordination

In March, 2007, ACP, the American Academy of Family Physicians, American Academy of Pediatrics, and the American Osteopathic Association released a joint statement of principles that defines the characteristics of a patient-centered medical home. These four organizations represent 333,000 physicians and medical students. (over)

The patient-centered medical home incorporates the relationships and systems required to support more effective care coordination for patients with multiple chronic diseases. As defined by the joint principles:

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home:

* Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.

* Evidence-based medicine and clinical decision-support tools guide decision making

* Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.

* Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met

* Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

* Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.

* Patients and families participate in quality improvement activities at the practice level.

The patient-centered medical home can improve the quality of care provided to any Medicare beneficiary, but is particularly suited to providing continuous, longitudinal, integrated and coordinated care for patients with multiple chronic diseases and/or dementia.

The following highlights recent news about stem cell- and emergency contraception-related legislation and proposals.

    * Florida: Lawmakers on Friday ended the session without approving two measures that would have provided state funds for stem cell research, the Lakeland Ledger reports (Lakeland Ledger, 5/5). One bill (SB 750), sponsored by Sen. Steven Geller (D), would have provided no less than $20 million annually for embryonic, amniotic and adult stem cell research for 10 years. A second proposed measure (SB 2496), sponsored by Sen. Mike Haridopolos (R), would have banned the use of state funding for embryonic stem cell research and would have provided an unspecified amount of money for research on stem cells harvested from sources such as umbilical cord blood. Gov. Charlie Crist (R) last summer during his gubernatorial campaign said he supported embryonic stem cell research and opposed President Bush’s veto of the Stem Cell Research Enhancement Act of 2005 (HR 810). However, earlier this year he proposed that the state spend $20 million on nonembryonic stem cell research based on likely opposition to embryonic stem cell research in the Republican-controlled state Legislature (Kaiser Daily Women’s Health Policy Report, 4/19). Lawmakers said the bills were not passed due to budget constraints. Crist said he would return to the issue in the next session (Lakeland Ledger, 5/5).

    * Massachusetts: Gov. Deval Patrick (D) on Tuesday unveiled a proposal that would provide $1.25 billion in grants during the next 10 years to state universities and hospitals to conduct embryonic stem cell research, the New York Times reports. The funds would establish special stem cell research centers, train workers for biotechnology businesses and create the first stem cell repository at the University of Massachusetts, where all stem cell lines created in state laboratories could be stored (Belluck, New York Times, 5/9). According to the proposal, the state would provide $25 million annually in direct research grants, offer $25 million annually in business tax incentives to biotech companies and issue $500 million in bonds over 10 years to pay for capital investments, the Boston Globe reports (Estes/Heuser, Boston Globe, 5/9). The plan also would involve an additional $250 million in matching funds from private business, the Times reports (New York Times, 5/9). Eight universities and hospitals have agreed to share their stem cells with the repository (Allen, Boston Globe, 5/9). Patrick said the majority of the investment would begin in July 2008 (Maguire, AP/Guardian, 5/8). According to the Times, Patrick’s proposal appears to have more support from the Legislature and less opposition from the public than similar proposals in California and some other states (New York Times, 5/9).

    * Minnesota: Gov. Tim Pawlenty (R) on Friday signed into law a measure (SF 1266) that will require state hospitals to offer rape survivors emergency contraception, the St. Paul Pioneer Press reports. Under the law, hospitals are allowed to give rape survivors a pregnancy test and are not required to offer EC if the test is positive (Stassen-Berger, St. Paul Pioneer Press, 5/4). The Senate last month voted 65-0 to pass the Compassionate Care for Sexual Assault Victims Act, and the House earlier this month voted 105-27 to pass the measure (Minnesota Legislature, 5/1).

The discomfort caused by esophageal (non-cardiac) chest pain is often severe, driving many patients to emergency rooms and physicians’ offices despite the fact that the ailment has no definable pathology. Although this pain may sometimes be the result of acid reflux disease, when this is absent most patients present hypersensitivity of the esophagus, and a recent study suggests a potential new way of managing this and other symptoms.

The study finds that theophylline, taken either intravenously or orally, appears to reduce esophageal chest pain by relaxing the esophageal wall and decreasing hypersensitivity. Lead author Satish S.C. Rao finds evidence that these beneficial effects may also be influenced by theophylline’s actions on adenosine receptors, altering esophageal sensory thresholds at the same time as relaxing the muscles.

Rao notes that "following oral administration, symptomatic improvement was seen in nearly 60 percent of patients, and the drug was reasonably well tolerated," adding that "if a cardiac, pulmonary, musculoskeletal or esophageal source such as acid reflux disease can be excluded, our findings suggest that a trial of theophylline may be effective in relieving chest pain."