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MGH Community News |
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MGH Community News |
| April 2013 | Volume 17 • Issue 4 |
Highlights
Sections
Social Service staff may direct resource questions to the Community Resource Center, Lindsey Streahle, x6-8182. Questions, comments about the newsletter? Contact Ellen Forman, x6-5807. |
Cambridge Health Alliance To Cut Pedi Mental Health Beds Cambridge Health Alliance said recently it will eliminate 11 of its 27 beds for treating children and teens with acute mental illness and will end inpatient care for its youngest children as it grapples with financial losses. The hospital system has two highly regarded inpatient units — one serving adolescents ages 12 to 19 and another for children as young as 3. The two units will be combined into one smaller unit serving patients ages 8 to 18, said Dr. Jay Burke, chief of psychiatry, and the hospital will focus more on providing community-based services including those that can keep children out of the hospital, such as services in schools and placing psychiatrists in pediatricians’ offices. While several other hospitals have psychiatry units that serve children of all ages, Cambridge Health Alliance’s Child Assessment Unit accounts for nearly one-third of the hospital beds in Massachusetts designated specifically for the younger age group, typically under 12. A Department of Public Health spokesman told the Globe it had determined that the bed reduction warrants a public hearing under a law requiring review of changes to “essential” medical services. A hearing date has not been set. -See the full The Boston Globe article... |
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US Hospitals Send Hundreds of Immigrant Patients Back to Home Countries to Curb Cost of Care
Hundreds of immigrants who are in the U.S. illegally have taken journeys through a little-known removal system run not by the federal government trying to enforce laws but by hospitals seeking to curb high costs. A recent report compiled by immigrant advocacy groups made a rare attempt to determine how many people are sent home, concluding that at least 600 immigrants were removed over a five-year period, though there were likely many more. |
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Now advocates for immigrants are concerned that hospitals could soon begin expanding the practice after full implementation of federal health care reform, which will make deep cuts to the payments hospitals receive for taking care of the uninsured.
Health care executives say they are caught between a requirement to accept all patients and a political battle over immigration. Hospitals are legally mandated to care for all patients who need emergency treatment, regardless of citizenship status or ability to pay. But once a patient is stabilized, that funding ceases, along with the requirement to provide care. The American Medical Association’s Council on Ethical and Judicial Affairs issued a strongly worded directive to doctors in 2009, urging them not to “allow hospital administrators to use their significant power and the current lack of regulations” to send patients to other countries. Doctors cannot expect hospitals to provide costly uncompensated care to patients indefinitely, the statement said. “But neither should physicians allow hospitals to arbitrarily determine the fate of an uninsured noncitizen immigrant patient.” -See the full The Washington Post article... Cited in/linked from HEALTH CARE WEEKLY UPDATE, Barbara Roop & John Goodson, Health Care for Massachusetts, April 26, 2013.
Little Nomads: Legal Advocacy for Youth The “Little Nomads” website offers youth a legal referral guide for general legal assistance, LGBTQ-specific topics, immigration, domestic violence, housing and criminal matters or CORI forms. See: www.littlenomads.org . -From: Housing & Benefits Committee e-mail, Kelly Turley, Mass. Coalition for the Homeless, April 17, 2013. MassAbility (formerly Mass Rehabilitation Commission): Vocational Rehab (Edited 10/24 to reflect agency name change.) The mission and vision of the MassAbility is to promote equality, empowerment and independence of individuals with disabilities. These goals are achieved through enhancing and encouraging personal choice and the right to succeed or fail in the pursuit of independence and employment in the community. MassAbility provides comprehensive services to people with disabilities that maximize their quality of life and economic self-sufficiency. MassAbility has three divisions: Community Living Services (CL), Disability Determination Services (DDS), and Vocational Rehabilitation (VR). Community Living Services (CL) include Home Care; Brain Injury and Specialized Community Services; Protective Services; Independent Living Services, Home Care Services; Assistive Technology; Independent Living for individuals Turning 22; and Consumer Involvement. The DDS Division is funded by the Social Security Administration (SSA) and determines the initial and continued eligibility for federal SSI and SSDI benefits. Special outreach efforts are made to homeless shelters and individuals with HIV. Vocational Rehabilitation (VR) Eligibility: the client must have a documented disability that is a substantial impediment to employment, and the impairment must be the primary reason the individual is unable to achieve adequate employment. Those receiving SSI or SSDI on the basis of disability are presumed eligible. (Paragraph added 5/14) The Vocational Rehabilitation Program assists people who have a disabling condition who would like to find or return to work. VR also works closely with employers in the community to help create job openings and to help increase employer awareness regarding the benefits of diversity in the workplace. A vocational rehabilitation counselor (VRC) will meet with the client from one of 25 field offices located throughout the Commonwealth. VR counselors are trained to work with people with disabilities to develop a plan to meet specific career goals based on the individual’s strengths, limitations and barriers to employment. The VR counselor will determine, in collaboration with the client, the services necessary to help achieve his/her goals and to enter or re-enter the world of work. The Process MassAbility will issue an eligibility determination in writing within 60 days after receipt of the signed application. If found eligible, the client would begin meeting with his/her VR counselor. This is a process that may involve several meetings to ensure that the client has all the information needed through the Vocational Assessment process to make sound decisions about a career path. The VR counselor and client will then agree on and finalize an Individual Plan for Employment (IPE). The IPE will list the client’s individualized employment goals and responsibilities, as well as the services MassAbility is responsible for providing to prepare the client for employment. As the services in the IPE come to a close, the client and counselor will be discussing going to work. During this time the client will be preparing to go on job interviews, designing a resume and learning interviewing techniques. Once the client is employed the counselor may still be able to help with problems such as transportation, reasonable accommodations, additional training and support services like job coaching. Client Rights Clients may seek resolution of problems or disagreements about rehabilitation services by contacting the VR counselor, counselor's supervisor and/or the office manager. Clients have a right to appeal any action or inaction affecting their rehabilitation services. A client must make a written request for appeal within 30 days of being notified of a change in, or denial of, services. For more information about MassAbility Programs and Services: -Adapted from http://www.workwithoutlimits.org/sites/default/files/DI_Spring_2013_FINAL.pdf Regulations: http://www.mass.gov/eohhs/gov/laws-regs/mrc/107-cmr-600-vocational-rehabilitation-services.html RAFT Homelessness Prevention Funds May Also Be Used for Utility Arrearages The Metropolitan Boston Housing Partnership (MBHP) currently has back rent and utility financial assistance available from the state's RAFT program (Residential Assistance for Families in Transition). Families with at least one child under 21 who are at or below 30% of the area median income and living in the MBHP service area (30 communities in Greater Boston- see list) may qualify for up to $4,000. They can also assist with mortgage arrears up to $4,000 for families meeting the income eligibility criteria. If the family is seeking back rent (arrears) assistance, they must have a Summary Process and Complaint form from the court system. If the family is seeking utilities assistance, they must have a shut-off notice from the utility company. If the family is seeking mortgage arrears assistance, they must a foreclosure notice from the bank. MBHP can also help homeless families with start up costs to move into a new unit. These fund may also be used to move currently housed families experiencing a housing crisis (natural disaster or condemned unit, as examples) or persons experiencing other emergencies (health or safety issues, as examples)]. RAFT Eligibility Details Families must
IF the family meets the above criteria, MBHP will then screen the family to determine RAFT eligibility. Families must also meet additional risk factors for homelessness to be considered for RAFT assistance! 2013 Income Limits (See 2014 Area Median Income limits)
Housing Crises
Required Documentation by Assistance Type
Required Documentation for All Families
Required Documentation for Subsidized Tenants If the Household receives assistance for rent arrearage, they must show proof of hardship such as medical expenses, loss of income, or other crisis. Medical verification of a disability that affects ability to pay rent or proof of a delay in rent adjustment is also acceptable. More Information Social Service staff can learn more on our RAFT page. -Adapted from RAFT Funds Available for Families e-mail, Metropolitan Boston Housing Partnership, April 22, 2013. Website Makes Finding a Clinical Trial Easier While we’d all like to have straightforward medical diagnoses with simple solutions, some of us get thrown curve balls: a rare disease that strikes fewer than 1 in 10,000 people, or a life-threatening illness with no known cure. In these cases, entering a clinical trial may make sense for patients. The government’s Clinicaltrials.gov website can be difficult to navigate, making it tough to find the appropriate trial to enter, even when a doctor is searching. “You have to be pretty sophisticated when searching this site since drugs are often listed by their original names, which are a bunch of letters and numbers,” said Dr. David Ryan, chief of hematology and oncology at Massachusetts General Hospital. Now there’s a new website called Myclinicaltriallocator.com that is designed to be more user-friendly. -See the full Boston Globe article ... Cancer Transitions- Free Survivorship Workshops at MGH The MGH Cancer Center has been awarded a LIVESTRONG® Community Impact Project Award from the Lance Armstrong Foundation. The funding from this grant has enabled us to offer a program designed to help cancer survivors make the transition from active treatment to post-treatment care. Cancer Transitions is a free 2½-hour, six-week workshop open to patients who have completed active treatment, but are no more than 2-years post treatment. Expert panelists including physicians, nutritionists and fitness experts will discuss exercise tailored to each participant’s abilities, training in relaxation and stress management and tips for nutritious eating. Cancer Transitions will answer many of your questions about cancer survivorship post-cancer treatment. The course covers the following topics: TIME: Wednesdays, 4:30pm-7:00pm May 15th, May 22nd, May 29th, June 5th, June 12th, June 19th LOCATION: Massachusetts General Hospital Cancer Center Blum Cancer Resource Room, Yawkey 8C For details and required registration, contact: Paula Gauthier, LICSW at 617-643-1784 See/share the flyer.
Major MA Healthcare Coverage Changes to come in 2014 Implementation of the federal health reform law, the Affordable Care Act, will result in major changes in subsidized health programs in Massachusetts in 2014. Overview:
Proposed Coverage Types In a draft proposal, from last July, the Commonwealth proposed the following new structure for subsidized health programs, with five main coverage types:
Under this new structure, many will experience changes in their eligibility for subsidized health programs; the Commonwealth is working to design the new coverage types to promote continuity of care and coverage to the greatest extent possible. Certain populations – such as those in the CommonHealth program, and immigrants who are ineligible for ACA coverage – have no required changes in their coverage. However, the Commonwealth is examining options for simplifying and streamlining coverage for these groups as well. Sources and For more information
Commonwealth Care Open Enrollment Period In the coming weeks, Commonwealth Care members will receive their 2013 Open Enrollment information packet. During Open Enrollment, members can change their health plan for any reason. This year, Commonwealth Care members can make a health plan change from June 3rd - June 21st. The Open Enrollment packets contain custom information about each member's health plan options. Important things to know about 2013 Commonwealth Care health plan options :
- Adapted from Call-In to Learn about the 2013 Commonwealth Care Open Enrollment Period e-mail, MA Health Care Training Forum, April 17, 2013. Medicare End-of-Life Dilemma: Hospice or Nursing Home End-of-life care decisions are never easy, but many Medicare recipients are being forced to choose between nursing home or hospice care benefits, although neither by themselves may be ideal for a patient nearing the end of life. Nursing homes are great for providing around-the-clock care, but in general, hospice care is considered to be better at treating end-of-life pain and suffering and for providing support for the patient and the patient's family. Although Medicare provides a limited nursing home benefit as well as hospice coverage, it usually doesn't reimburse for both benefits at the same time, forcing recipients to pay out-of pocket for one or the other (unless the patient is receiving the care for separate illnesses.) Medicare covers up to 100 days of "skilled nursing care" per illness following a hospitalization. This coverage includes the cost (plus a co-payment after 20 days) of a semi-private room, meals, skilled nursing and rehabilitative services, and medically necessary supplies. Meanwhile, Medicare's hospice benefit covers doctor and nursing services, medical supplies, drugs, home health aide services, counseling and spiritual care, among other things, but it does not cover room and board. -Read the full article from Margolis & Bloom/ElderLawAnswers.com...
Earlier this month, in an effort to support cheaper transportation for seniors and the disabled, the Mass. Senior Action Council hosted a rally against The RIDE fare increases. Hundreds of riders, some of whom said they would be stranded at home if the MBTA continues to increase fees in order to use the RIDE services, gathered outside the State House to voice concerns about the rising cost to utilize the public transportation option. The protestors decried a new joint transportation bill put forth by the Senate and House of Representatives this month while also calling for a rollback of the increase implemented on The RIDE last summer. According to reports, use of The RIDE decreased dramatically since the price to take the services skyrocketed in 2012. A one-way fare on the system shot up from $2 to $4 last July. The price was raised to address a looming budget gap and to fund the service. Users of The Ride and advocates contend that those in need of paratransit services have had to shoulder the burden of disproportionate fare increases. The legislature’s proposed bill would pump $500 million into transportation investments by increasing the gas tax and adding a $1 fee to the cost of tobacco. But Governor Deval Patrick, who floated a more extensive transportation funding option earlier this year, has vowed to veto the bill if it comes before him, calling it a “short-term fiscal shell game” that will cost the taxpayers more money without fixing the state’s roads and public transit options. -See full coverage in BostonMagazine.com... Mass. Businesses Don’t Like Insurance Decision Massachusetts business leaders say they are disappointed with a federal decision to allow the state to phase in parts of the national health care law over three years, maintaining it doesn’t do enough to provide relief from expected insurance premium hikes. After state officials earlier this year objected to new rules stemming from the US health care overhaul — arguing they would drive up costs for small businesses and their employees — federal health officials told their Massachusetts counterparts earlier this month that the state could take until 2016 to fully implement rules to bring it into compliance with national standards. But business leaders responded that the federal decision, while welcome, fell short of the waiver they had sought for regulations that conflicted with Massachusetts’ 2006 health care law, widely viewed as the model for the US Affordable Care Act. “We had hoped for a complete waiver,” said Jon Hurst, president of the Retailers Association of Massachusetts, who had complained US rules would eliminate state “rating factors” that allow premium discounts for small business cooperatives that included wellness initiatives. Currently, the state lets insurers weigh about 10 factors in setting rates for small businesses. The federal government has mandated only four rating factors — age, number of family members, geographic area, and tobacco use. Eric Linzer, senior vice president of the Massachusetts Association of Health Plans, said state health insurers hope to work with the Patrick administration to change other federal rules not addressed by the phase-in, such as a requirement that insurers submit rates for small businesses and individuals annually on July 1 for the following calendar year. Insurers and small businesses have said that also could drive up rates. -See the full Boston Globe article ... HCAN Says Pharma Charges Medicare D Inflated Prices Ethan Rome, Executive Director for the not-for-profit Health Care for America Now (HCAN), recently wrote an Op-Ed for the Huffington Post indicating that over the past decade, 11 major pharmaceutical companies cashed in on $711 billion in profits while older adults, taxpayers, and consumers were stuck with the tab. HCAN reviewed the financial statements of these companies and concluded that many of them engaged in price-gouging: charging Medicare Part D inflated prices for their drugs (for which Medicare was not allowed to negotiate). In fact, after the implementation of Medicare Part D in 2006, the combined profits of the largest companies spiked to 34 percent above profits from the previous year. In 2012, annual profits reached $83.9 billion, a staggering 62 percent jump from 2003. The US spends about 40 percent more than Canada, 75 percent more than Japan and three times more than Denmark, per capita, on prescription drugs. According to the Congressional Budget Office (CBO), allowing Medicare to get similar “bulk purchasing” discounts on prescription drugs as state Medicaid programs would save the federal government $137 billion over 10 years. HCAN and the Medicare Rights Center strongly support allowing Medicare to secure more reasonable drug prices. -See the full Huffington Post post ... -Adapted from The Cost of Compromise, Medicare Watch, Volume 4, Issue 15,The Medicare Rights Center, April 11, 2013. New Report Examines Ways to Reduce Barriers to Receiving Long Term Care The Scan Foundation recently released a report outlining challenges in financing long-term health services and supports (LTSS) for the elderly. The report, written by staff at the National Academy for Social Insurance (NASI), lists policy options to make LTSS more affordable in the future. Even as the costs for LTSS have risen, demand for such care has also increased due to a larger aging population. According to the report, a small but noticeable share of the older adult population will end up with long-term health costs well over $250,000. This is because the vast majority of people have no protection against the financial costs of long-term disability. Although Medicaid protects certain people, budgetary constraints have put pressure on politicians and policy makers, especially at the state level, to cut back even further on essential benefits. In the report, the Scan Foundation and NASI propose to institute an insurance-based model to ensure that many more people, not just those who qualify for Medicaid, have a chance to protect themselves against LTSS costs. The Foundation proposes a universal compulsory program, much like the one implemented (and subsequently abandoned) in the Affordable Care Act, that compels people to buy long-term care insurance, thereby spreading this risk broadly. This could be done by:
The Scan Foundation and NASI determines that a universal compulsory program could improve access to affordable LTSS, lessen the financial impacts of these services on state Medicaid programs, and allow Americans to take greater personal responsibility for their long term care. - Article adapted from Medicare Watch Volume 4, Issue 14, The Medicare Rights Center, April 04, 2013. Obama Proposes Social Security Cuts President Barack Obama’s proposed budget calls for reductions in the growth of Social Security and other benefit programs while still insisting on more taxes from the wealthy in a renewed attempt to strike a broad deficit-cutting deal with Republicans, a senior administration official says. The proposal aims for a compromise on the Fiscal 2014 budget by combining the president’s demand for higher taxes with GOP insistence on reductions in entitlement programs. A key feature of the plan Obama for the federal budget year beginning Oct. 1 is a revised inflation adjustment called ‘‘chained CPI.’’ This new formula would effectively curb annual increases in a broad swath of government programs, but would have its biggest impact on Social Security. By encompassing Obama’s offer to Boehner, R-Ohio, the plan will also include reductions in Medicare spending, much of it by targeting payments to health care providers and drug companies. Administration officials have said Obama would only agree to the reductions in benefit programs if they are accompanied by increases in revenue, a difficult demand given the strong anti-tax sentiment of House Republicans. If the chained CPI were implemented, Social Security benefits would be about $3 per month lower in 2014, and about $30 a month lower by 2023, according to Congressional Budget Office calculations. And by 2033, Social Security payments are projected to be 3 percent lower than they would be using the current measure of inflation. "The impact would be greater the longer people received benefits, that is, the more reduced cost-of-living adjustments they experienced" said Jeffrey Kling, associate director for economic analysis at the Congressional Budget Office. "The impact would be especially large for some disabled beneficiaries; they generally become eligible for Social Security benefits before age 62 and thus can receive cost-of-living adjustments for a longer period." Obama’s proposal, however, includes calls for increased spending. It would make pre-school available to more children by increasing the tax on tobacco. Sources and for More Information
Opinion: President’s Budget Seeks Too Costly Compromise for People with Medicare President Obama’s fiscal year 2014 budget includes some provisions for sustaining Medicare, including eliminating wasteful spending in the program and building on new, efficient program innovations made possible by the Affordable Care Act (ACA). The President’s budget tackles Medicare’s drug costs by accelerating the closure of the Part D coverage gap (or doughnut hole) and restoring drug rebates in the Medicare program for people with low incomes. However, the President’s budget also includes proposals that would increase costs for Medicare beneficiaries. These proposals would increase premiums for middle-income beneficiaries, tax Medigap plans, and increase beneficiaries’ deductibles and copays. The Medicare Rights Center argues that cutting federal spending by shifting costs to older adults and people with disabilities is no way to balance the budget and fails to address the real problem—rising health care costs in the system overall. The proposals included in the President’s budget aim for compromise, but that compromise would come at too great a cost for Medicare beneficiaries. -Read Medicare Rights’ Press Release Opinion: Huge Win for the Insurance Lobby & Loss for Sensible Health Policy Health insurers won a remarkable victory this month. The Department of Health and Human Services (HHS) said it would raise payments to private Medicare plans, rather than cut them as it had suggested in February. Instead of cutting payments for Medicare Advantage plans, it will increase them by 3.3 percent. Insurers’ stocks jumped. Hopes for sensible health policy sank. The February proposal, which cut the per-capita growth rate in Medicare payments, was not well crafted. The cuts would have added to existing reductions in Obamacare. The change shows the immense power wielded by health insurers. America’s Health Insurance Plans (AHIP), the industry’s lobby, bought television advertisements and rallied allies in Congress. They argued that the administration was using faulty methodology. The insurers mounted a vigorous campaign, using television ads and phone banks, to persuade lawmakers to oppose the reduction. On Monday, the Centers for Medicare and Medicaid Services (CMS) announced that it was changing its method of calculating reimbursement rates. Instead of cutting payments for Medicare Advantage plans, it will increase them by 3.3 percent. Other efforts to find savings in health care may be similarly fruitless. Democrats and Republicans agree on few things, but with the medtech lobby they stand united. Last month the Senate voted, 79-20, to repeal Obamacare’s tax on medical devices. The industry has spent more than $90m on lobbying since 2010, when the law was passed. The cut would have been one of several directed at the Medicare Advantage program. The plans still face payment reductions and a new tax under the 2010 health-care law. Sources and for More Information
Both Cited in/Linked from: HEALTH CARE WEEKLY UPDATE, Barbara Roop & John Goodson, Health Care for Massachusetts, April 05, 2013.
Evidence Indicates That Exercise Lowers Cancer Mortality The study authors systematically reviewed 45 studies that examined relationships between physical activity and mortality (cancer-specific and all-cause) and/or cancer biomarkers. The review found there was consistent evidence from 27 observational studies that physical activity is associated with reduced all-cause, breast cancer–specific, and colon cancer–specific mortality. There is currently insufficient evidence regarding the association between physical activity and mortality for survivors of other cancers. Randomized controlled trials of exercise that included biomarker endpoints suggest that exercise may result in beneficial changes in the circulating level of insulin, insulin-related pathways, inflammation, and, possibly, immunity; however, the evidence is still preliminary. -See the full Medscape article summary ... Impact of Lifestyle Factors on Prognosis Among Breast Cancer Survivors A recent meta-analysis found that a multitude of studies investigating the impact of lifestyle modification on breast cancer survivors have produced highly variable and contradictory results. Large-scale dietary studies indicate that specific dietary components may not affect breast cancer mortality, but achieving and/or maintaining a healthy bodyweight through diet provides health benefits to breast cancer survivors. A body of research has definitively linked physical activity to improved prognosis and survival in breast cancer patients. Chronic stress appears to have an adverse effect on breast cancer incidence and survival, particularly in women with the highest levels of anxiety and depression. Although the actual benefits of psychosocial interventions remain controversial, yoga has shown promising effects on psychological health. Lifestyle factors considered in this review are unlikely to exert a uniform influence on outcomes in breast cancer survivors, thus modalities such as physical activity are likely to have a more significant influence than specific dietary components such as green tea or soy. These findings illustrate the need for continued, high-quality research into the effects of lifestyle interventions in breast cancer patients in order to provide survivors with state-of-the-art knowledge and optimum methods for improving long-term prognosis and QoL. Citation: Expert Rev Pharmacoeconomics Outcomes Res. 2012;12(4):451-464. -See the full Medscape summary article...
Talking with Teens About Confidentiality Kenneth R. Ginsburg, MD, an adolescent medicine specialist at the Children's Hospital of Philadelphia, recently shared the following expert commentary on Medscape.com. It is widely accepted that a confidential relationship with a healthcare professional during adolescence is key. So how do we talk about this? The way that we were all taught to talk about this is to say, "I want you to know that we are going to have a confidential relationship. Everything will be kept confidential unless I'm worried that you are going to hurt yourself, hurt someone else, or that someone else is hurting you." The problem is that when we say that, kids have no idea what we're talking about, and they shut down and withhold information. Why? Kids don't know what the word "confidentiality" means. Ask kids, and what they will say to you is: "Thank you, Doctor. I am going to try to have confidence in you, too." So we have to choose a different word. We have to choose a word like "privacy." "Your information is important and for that reason I promise you privacy." In medicine we call that confidentiality. Don't use the word "secret" because secret is shameful. Next, don't tell kids, "I am worried that you are going to hurt yourself or hurt someone else or someone is hurting you; I'm going to have to tell someone." Why? Think about it from a 16-year-old's perspective. Does a 16-year-old think that you think doing drugs hurts them? Yes, they do. Does a 16-year-old think that you think that having sex without a condom hurts them? Yes, they do. So what they hear is entirely different from what we intended. If we want to build trust and create an opportunity for them to disclose the kind of information we need to hear, we need to be explicit. Instead, say: "I am going to keep your information private because I know how important it is, and I need for you to know that this is a place to learn and it is worthy of your trust. I also need you to know that I would need to break privacy, because I would need to support you to get help, only under 3 conditions: if I was so worried about you that I thought your life was in danger, meaning that you were going to kill yourself or you were going to kill somebody else or if there was an adult that was abusing you in any way. Then I would need to get you help right away. But everything else, whether we are talking about stress or feelings or sadness, whether we are talking about drugs or sex -- that is stuff where I am going to honor your privacy so that this place is a safe place for you to move forward and for you to learn and to make wise decisions." At the same time, we can share with them that we know that their parents are the most important people in their lives, and we don't want them to be angry at us when we suggest that we talk to their parents together. They are in control of that decision. -See the full Medscape expert commentary... Flashbacks Plague Many Former ICU Patients Recently researchers have described a troubling phenomenon: Not only do survivors of the ICU suffer high rates of depression and cognitive dysfunction, but also as many as one in three who are sick enough to require a breathing tube also develop symptoms of post-traumatic stress disorder. While it is more likely to occur in patients with preexisting depression, it can also appear in those without any psychiatric history. A soldier suffering from PTSD may experience flashbacks of tanks and bombs, terrifying moments of their waking life. In contrast, an ICU survivor may suffer flashbacks of delirium-induced nightmares they had in the hospital, rather than real events. While this is not PTSD as traditionally defined, physicians argue that it is no less debilitating. “You tend to believe you’re the only one,” says Nancy Andrews, a Maine filmmaker and college professor who suffered symptoms of post-traumatic stress disorder after a lengthy hospitalization in Boston for a life-threatening tear in the wall of the aorta. “You wonder what is wrong with you? You made it out of the hospital, why can’t you get it together?” The idea that delirious hallucinations could lead to post-traumatic stress disorder is new even for physicians who work in the ICU daily. Historically, patients were heavily sedated throughout their critical care stay with the dual goals of pain control and amnesia, to prevent patients from having memories of painful breathing tubes, or urinary catheters. However, research in the past decade has led to a paradigm shift. In 2000, the New England Journal of Medicine published data showing that interrupting sedation daily in intubated patients shortened the amount of time on a breathing tube, and got patients out of the ICU faster. Daily interruptions of sedation, termed “sedation holidays,” became standard. Fast forward a few years, and physicians now know that delirium itself — the waxing and waning alertness that often afflicts the critically ill who have been sedated — is associated with higher mortality, longer stays in the ICU, and higher costs. These findings have ushered in new practice guidelines, medication changes, and scoring systems to measure patients’ level of delirium. Already, practitioners are moving away from the medications most likely to cause delirium. Given the association between delirium and flashbacks, studies suggest these same medications are more likely to be associated with patients’ developing PTSD. But the sickest in the ICU will continue to require deep sedation. This has led researchers to question: If the absence of memory is at fault, would providing patients with a record of their hospital stay help? That rationale led to the creation of the ICU diary, a day-to-day record of a patient’s ICU stay, in simple language and with photographs. Christina Jones, a nurse consultant in the United Kingdom and her colleagues have recently published data showing that patients who are given diaries of their ICU stay exhibit significantly lower rates of PTSD than their counterparts without such a record. In the United States, ICU diaries are not widespread. Jones contributes to a website that serves as a worldwide network for health care workers interested in starting an ICU diary program. There are just a handful of hospitals that have joined, but momentum is growing. In Boston, nurses at Massachusetts General Hospital have started creating diaries for ICU patients who are expected to have a protracted course of sedation while attached to a breathing tube. -See the full Boston Globe article ... Meditation, Mindfulness Exercises Reduce PTSD Symptoms Mindfulness treatment that includes meditation, stretching, and emotional acceptance can help lower symptoms of posttraumatic stress disorder (PTSD), new research suggests. A small (n=37) pilot study of veterans with combat-related PTSD showed that 73% of those who received 8 weeks of mindfulness-based cognitive therapy (MBCT) had significant reductions in overall PTSD symptoms compared with 33% those who underwent treatment as usual (TAU). The intervention group also showed significant decreases in avoidance and numbing symptoms. The MBCT groups had a significant 11-point mean decrease in total CAPS score (P < .001). There was not a significant reduction in total CAPS score or any subscale score for the TAU groups. Although the results are encouraging, Lead author Anthony P. King, PhD noted that more studies with larger sample sizes are needed. One such larger study is currently underway by the investigators and includes military veterans returning from Afghanistan and Iraq. "Further research is needed to determine whether mindfulness training is more aptly considered an adjunct option to the gold-standard treatment of prolonged exposure, or whether [these therapies] can function as interventions...in their own right," write the investigators. The study was published online April 17 in Depression and Anxiety. -See the full article summary: Meditation, Mindfulness Exercises Reduce PTSD Symptoms. Medscape. Apr 26, 2013. Cannabis Use in Teens Linked to Irreparable Drop in IQ Cannabis users who start smoking the drug as adolescents show an irreparable decline in IQ, with more persistent use linked to a greater decline, new research shows. On the other hand, adult-onset cannabis use is not linked to a decline in IQ. "Our results suggest that adolescents are particularly vulnerable to develop cognitive impairment from cannabis and that the drug, far from being harmless, as many teens and even adults are coming to believe, can have severe neurotoxic effects on the adolescent brain," lead investigator Madeline H. Meier, PhD, from Duke University, Durham, North Carolina, told Medscape Medical News. In the current study, Dr. Meier and colleagues used data from the Dunedin Longitudinal Study, which was conducted in Dunedin, New Zealand. This prospective study included a birth cohort of 1037 individuals born in 1972 and 1973, who were followed from birth and were seen every 2 years to age 38. "This study has collected prospective life histories on its participants and had 95% retention," Dr. Meier said. Participants' cannabis use was ascertained in interviews at ages 18, 21, 26, 32, and 38 years. IQ testing was done at age 8, 11, and 13 years, before the start of cannabis use, and again at age 38, after a pattern of persistent cannabis use had developed. One third of the cohort had never used cannabis. After controlling for alcohol or drug dependence, socioeconomic status, and years of education, the researchers found that persistent cannabis use was associated with IQ decline when it was begun during the teenage years but not when begun in the adult years, after the age of 18. Between the ages of 8 and 38 years, individuals who began using cannabis in adolescence and continued to use it for years thereafter lost an average of 8 IQ points. In contrast, IQ among individuals who never used cannabis actually rose slightly, Dr. Meier said. Cessation of cannabis did not restore IQ among teen-onset cannabis users, she added. -See the full article summary: Cannabis Use in Teens Linked to Irreparable Drop in IQ. Medscape. Apr 26, 2013. |