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Newswise — Critically ill patients who recover from a potentially deadly syndrome known as acute lung injury frequently emerge with new, apparently long-lasting depressive symptoms and new physical impairments that make them unable to perform many daily tasks, Johns Hopkins research suggests.

Results of the new study, published in the American Journal of Respiratory and Critical Care Medicine, also suggest that the depressive symptoms frequently precede the new physical impairments, not the other way around. The research team also said the findings may be applicable to patients with other types of disease or injury who spend time in hospital intensive care units hooked up to ventilators that breathe for them.

“When people are discharged from the ICU, we tend, understandably, to focus on their physical health, but our data tell us we need to focus on their mental health, too,” says study leader O. Joseph Bienvenu, M.D., Ph.D., an associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. “Depression can make recovery much more difficult. Identifying depressive symptoms early — and treating them — could make a real difference in how patients fare physically in the long term.”

Bienvenu and his colleagues assessed 186 survivors of acute lung injury from four Baltimore hospitals at three, six, 12 and 24 months after they became ill, and surveyed their levels of depression as well as their ability to independently perform important tasks of daily life, such as using the telephone, shopping and preparing food.

The Hopkins team found that 40 percent of the patients developed depressive symptoms in the first two years after discharge even though they had not previously experienced them, and that 66 percent experienced new physical impairments. The average age of patients in the study was 49 years — people who should be in the prime of their lives but became disabled and unable to return to work, the researchers say. The researchers are continuing to follow these patients to see if the problems persist for an even longer period of time.

“Patients are burdened for a very long time after their hospital stays,” says principal investigator Dale M. Needham, M.D., Ph.D., an associate professor of pulmonary and critical care medicine and physical medicine and rehabilitation at the Johns Hopkins University School of Medicine. “We need to figure out what we can do to help these previously productive people get back their lives.”

Needham says it is unclear whether it is the acute lung injury syndrome itself causing the new problems or whether the cause is to be found in how patients are routinely cared for in ICUs. Standard ICU care for patients with acute lung injury often includes deep sedation and bed rest. Long stretches of inactivity are known to cause physical impairment, and the use of high-dose benzodiazepines to sedate ICU patients has been associated with depressive symptoms. Needham suspects that both critical illnesses themselves and typical ICU practices contribute to negative outcomes.

Patients’ lungs typically recover relatively quickly from acute lung injury, a syndrome often caused by pneumonia, but also by other infections or trauma. In acute lung injury, the body’s inflammatory response is revved up and gets out of control, causing fluid to flood into the breathing spaces of the lungs and respiratory failure. An estimated 190,000 Americans suffer from acute lung injury each year and more than 74,000, almost 40 percent, will die while in hospital.

Needham says it is important that intensivists like himself, and psychiatrists like Bienvenu work together to ensure the best outcomes for patients, a collaboration that is frequently missing in the care of ICU patients.

Bienvenu says he was surprised by the finding that depressive symptoms frequently precede new physical impairments, since the conventional wisdom is that the inability after an ICU stay to do things like grocery shopping, driving and walking long distances causes patients to feel demoralized about the loss of these functions. But the reverse appears to be true, he says. Depressed patients, he suggests, are harder to motivate to do the physical activities necessary for recovery and maintenance of function.

Bienvenu says acute lung injury is considered an archetypal critical illness and that its consequences may be present to one degree or another in patients who have suffered other critical illnesses. “All doctors should look out for these symptoms in their patients who have been in the ICU,” he says.

PR Web

Cambridge, MA (PRWEB) December 07, 2011

The early impact of the 2007 New York workers’ compensation reforms is identified by the Workers Compensation Research Institute (WCRI) in a new study, Early Impact of the 2007 Reforms in New York, designed to evaluate whether the regulatory changes met stated objectives.

The key regulatory changes increased maximum statutory benefits, limited the number of weeks of permanent partial disability (PPD) and developed a fee schedule for pharmaceuticals. This report is the fourth in a series monitoring the performance of the New York workers’ compensation system benefit delivery system.

“This report is a significant tool for assessing the performance of the New York workers’ compensation system following the implementation of major reforms,” said Ramona Tanabe, WCRI’s Deputy Director and Counsel. “It will help public policymakers, employers, insurers and other stakeholders determine whether the changes were successful in meeting their goals and identify any unintended consequences.”

The increase in the maximum weekly benefit resulted in the increase of the average temporary total disability benefit by 19 percent after the implementation of the second of three increases in the benefit rate.

As planned, these increases in maximum weekly benefits have brought New York closer to national rates and reduced the percentage of workers whose benefits were limited by the maximums. For example, the percentage of injured workers whose benefits were limited by the maximum benefit fell from 48 percent prior to the first increase to 29 percent after the second increase. WCRI estimates that the third increase in the maximum will reduce this percentage to 24 percent.

The study found a shift for PPD/lump sum cases at an average of 12 months experience – a 10 percentage point decrease in claims that received PPD payments only (no lump sum) and an 11 point increase in claims with a lump sum settlement only (no PPD payments).

WCRI observed that although the limitation on the weeks of PPD wage replacement benefits is expected to result in significant savings, it will likely be several years before the effect is reflected in the data.

The study also reported that the implementation and subsequent change of the pharmacy fee schedule had the effect of decreasing the average price per pill by 10 to 20 percent.

The state-based workers’ compensation system has evolved and survived for 100 years but it could face tough challenges in the coming years as the country struggles to dig itself out of the deep recession.

The recession has caused an “unprecedented disruption of the labor market” that will have widespread and long-term effects, according to a leading workers’ compensation researcher and economist.

Richard Victor, executive director of the not-for-profit Workers’ Compensation Research Institute (WCRI), is warning that one economic fact alone could trigger a re-examination of workers’ compensation and other job-related programs. It is that there are 25 million Americans vying for just 3.5 million available jobs. That’s seven people for every opening.

Victor dubbed this employment crisis the “elephant in the room” during his organization’s annual research conference in Boston.

The 25 million includes the unemployed and underemployed. In a normal economy, there might be half that many looking for work, he said.

Victor believes the issues raised by today’s unemployment crisis are structural. He said that there is a mismatch between the Americans looking for employment and many of the jobs available. In relation to workers’ compensation, Victor said many of the available jobs are “not matched to the skills, interests and location of injured workers.”

The point has been underscored by the president of the Federal Reserve Bank of Minneapolis. Narayana Kocherlakota sees mismatch by geography, skills and other factors as a major issue and estimates this adds about 2.5 point to the unemployment rate.

The issues are not just temporary, in Victor’s view.

Just to fill the jobs gap left by the recession, the country needs to create about 6 million jobs; then it needs another 7 million jobs to keep pace with those newly entering the job market, Victor said.

According to the Wall Street Journal, the labor market lost almost 8.8 million jobs from a peak in January 2008 (138 million payroll jobs, when the unemployment rate was 5 percent) to the bottom in February 2010 (129.2 million).

The labor market needs to be producing far more jobs, as many as 300,000 a month to get back to normal levels of unemployment within five years.

Job creation will depend upon how fast the gross domestic product grows. Many economists expect GDP to grow less than 2.5 percent for the rest of this year and for all of next. At that rate, the economy will add just 125,000 jobs a month, barely keeping up with population growth.

Even at an optimistic GDP growth of 3.1 percent a year, it could take a decade or more for the country to get back to any “normal” employment situation, Victor said.

“So this [high unemployment] is going to be with us a long time,” said Victor.

The WCRI economist suggested that as society grapples with this chronic unemployment, job-related programs could come under pressure and state workers’ compensation systems could be drawn into a bigger debate over how to help pay for extended unemployment.

“How will the system cope?” he asked his WCRI audience of about 250.

He painted a potential scenario where employers, injured workers and public policymakers begin asking questions about workers’ compensation, questions that have been settled by state workers’ compensation systems in the past, but ones that may be re-opened because “it’s a different environment.”

Injured workers may ask if they will ever be rehired or if they should try to hold onto their workers’ comp benefits longer since no jobs are available.

There are 200,000 workers injured every month in the U.S. and the probability of re-employment goes down the longer someone is out of work, he said.

Employers may face more litigation as more workers turn to attorneys to help them fight for benefits. Business owners may start asking if benefit formulas should be reworked or standards for terminating benefits be revisited.

Also, some may question anew the feasibility of return-to-work, rehabilitation or retraining programs since few jobs are available.

Also in Victor’s scenario, state workers’ compensation boards will face bigger workloads. There could be more delays and longer durations for payments. The system, and its costs, may become less predictable. Some state systems may be more vulnerable than others.

Victor said he is particularly worried about those who will be entering the labor market over the next five to seven years and face limited opportunities. “This can have profound, long term effects,” he said.

To open the day and one-half WCRI research conference in Boston, Peter Barth, professor of economics (emeritus) at the University of Connecticut and long-time researcher and consultant on workers’ compensation issues, reviewed the 100-year history of workers’ compensation over which the system has evolved but stayed fundamentally the same.

“Have there been improvements? Yes,” Barth said. “Is there still room for improvement? Yes.”

WCRI attendees also heard advice on how to measure and manage workers’ compensation medical costs, how to improve patient care involving narcotics, and recommendations of alternative approaches to managing chronic pain.

Then Victor closed the conference with his much-anticipated “elephant” talk.

“The elephant’s coming. Be prepared,” he told his WCRI audience.

WCRI is an independent, not-for-profit research organization based in Cambridge, Mass.

Former employees of Zynga describe a demanding workplace that includes loud outbursts by its chief, Mark Pincus.

Zynga’s chief executive, Mark Pincus, got an earful from employees last month.

In dozens of e-mails to a companywide list, frustrated workers complained about the long hours and stressful deadline periods. The quarterly staff survey solicited 1,600 responses, with plenty of criticism, including one person who said he planned to cash out and leave after the initial public offering.

Mr. Pincus took note, going through the comments and highlighting select excerpts. At a Zynga meeting several days later, he read some of the most acerbic words. Mr. Pincus said he was aware of the problems, but needed the staff’s guidance to fix them.

Few Internet start-ups have grown as swiftly as Zynga, creator of a sprawling network of virtual farms, cities and poker tables that is preparing to go public in one of the most highly anticipated offerings this year.

Jeff Chiu/Associated PressZynga employees in its Mafia Wars 2 studio. The company has autonomous teams for each game, like FarmVille and CityVille.

Led by the hard-charging Mr. Pincus, the company operates like a federation of city-states, with autonomous teams for each game, like FarmVille and CityVille. At times, it can be a messy and ruthless war. Employees log long hours, managers relentlessly track progress, and the weak links are demoted or let go.

But that culture, which has been at the root of Zynga’s success, could become a serious liability, warn several former senior employees who agreed to speak on the condition of anonymity because of fear of reprisals.

As the discord increases, the situation may jeopardize the company’s ability to retain top talent at a time when Silicon Valley start-ups are fiercely jockeying for the best executives and engineers. It could also hamper deal-making, a critical growth engine for Zynga, which has spent about $119 million on acquisitions in the last two years.

“Zynga should be an example of entrepreneurship at its best,” said Roger McNamee, a co-founder of the venture capital firm Elevation Partners. “Instead it’s going to be a Harvard Business School case study on founder overreach — this will be a cautionary tale.”

Already, signs of trouble are emerging.

In July, Zynga lost a bid for PopCap, a mobile game company. Zynga offered $950 million in cash.

But PopCap’s founders worried about the company’s reputation after hearing rumors of the company’s rescinding share awards and fierce internal competition, said two people with first-hand knowledge of the situation. Instead, PopCap agreed to a rival offer from Electronic Arts, worth $750 million in cash and stock and the potential of an additional $550 million if certain earnings goals were met.

Several start-ups have also rebuffed Zynga this year, including Rovio. This summer, Rovio, the maker of the popular mobile game Angry Birds, walked away from discussions of a deal worth roughly $2.25 billion in cash and stock, three people briefed on the situation said.

With the I.P.O. fast approaching, competitors are preparing to poach disgruntled staff members. This month, one recruiting firm sent cookie baskets to some 150 Zynga employees.

“I expect a lot of game and tech companies will begin recruiting Zynga’s talent after their equity becomes liquid,” said Gabrielle Toledano, head of human resources for Electronic Arts. “Competitors will make the case that they offer much more compelling opportunities for creative people.”

Zynga declined to comment, citing the mandatory quiet period before its I.P.O.

While from the outside Zynga may have the fun and whimsy of the Willy Wonka chocolate factory, the organization thrives on numbers, relentlessly aggregating performance data, from the upper ranks to the cafeteria staff.

General managers submit weekly reports, measuring factors like traffic and customer satisfaction. Every quarter, teams assess their priorities under an Intel-pioneered system called “objectives and key results.” And Mr. Pincus, a professed data obsessive, devours all the reports, using multiple spreadsheets, to carefully track the progress of Zynga’s games and its roughly 3,000 employees.

“It’s very similar to a New York investment bank,” said Lou Kerner, an analyst at the brokerage firm Liquidnet, who has followed Zynga for years. “It’s data-driven, and it’s intense.”

The data pipeline allows Zynga to fine-tune its games to optimize engagement, helping the company attract some 270 million unique users each month, many through Facebook. The four-year-old Zynga, which has emerged as the Web’s largest social game company, recorded $828.9 million in revenue in the first nine months of 2011, more than double the period a year earlier. It is also the rare Internet start-up that is profitable, earning $121 million since the start of 2010.

But the heavy focus on metrics, in this already competitive industry, has also fostered an uncompromising culture, one where employees are constantly measured and game designers are pushed to meet aggressive deadlines. While some staff members thrive in this environment, others find it crushing. Several former employees describe emotionally charged encounters, including loud outbursts from Mr. Pincus, threats from senior leaders and moments when colleagues broke down into tears.

For the top performers, the rewards are handsome. Zynga dispenses lavish gifts like vacations and $100,000 in vested stock. After the game Mafia Wars reached a milestone two years ago, Zynga sent the team to Las Vegas to celebrate, buying some 80 plane tickets and providing $500 in cash for each person and luxury hotel accommodations, according to one former senior employee.

Those who do not perform can perish.

In March 2009, Zynga hired its chief people officer, Colleen McCreary, who formalized the hiring structure and started to trim weak performers, cutting about 30 employees by that summer. Mr. Pincus began drafting “M.I.A.,” or missing-in-action, lists to keep track of senior employees who were not doing a good job or who needed to be placed on more ambitious projects.

That year, Zynga also started to reduce equity packages through demotions. Some employees were offered a choice: take another role with the same salary and a smaller equity package, or leave the company. It affected only a limited number of senior employees, several people close to the company said.

“If I was egregiously failing, then maybe it would be O.K.,” said one former senior employee, who left after being asked to give back some equity. But “it seemed systematically driven.”

The practice, even if rarely applied, runs counter to the traditional Silicon Valley model, where people join risky, unproven start-ups in exchange for substantial equity. But Mr. Pincus, a graduate of Harvard Business School and a former Wall Street hand, sees Zynga in a different mold, aiming to build a more perfect meritocracy, according to people close to him.

“Mark Pincus has the reputation that he is driven to the point of a madman,” said Michael Pachter, a Wedbush Securities analyst. “Zynga is driven because it has a gigantic competitive advantage right now.”

But Zynga could face a serious reaction.

In the spring of 2009, Zynga was courting MyMiniLife, a game company that later developed the underlying technology for FarmVille and many of Zynga’s games. During one meeting, the topic turned to compensation. A Zynga senior vice president, clad in jeans and leather cowboy boots, whipped out his wallet and a stack of hundred-dollar bills. He chucked the money at a MyMiniLife founder and asked him if that was enough, said one person present at the meeting.

“It was insulting,” this person said.

While MyMiniLife eventually agreed to a deal that formed the backbone of FarmVille, discontent soon surfaced. The team was stretched, juggling tough deadlines, technical flaws and demands for more data, according to two former employees. A few months later, as FarmVille approached 20 million users a day, a respected project manager abruptly quit the team. Soon after, the majority of the game’s staff members, including those of the just-acquired MyMiniLife team, threatened to walk out unless Zynga replaced the group’s general manager, these people said. The company relented.

While such a culture is not uncommon in the game industry, it can create problems. Employees at Electronic Arts and Activision Blizzard have filed lawsuits against their employers, with claims of hostile work conditions and withheld compensation. In 2006, Electronic Arts settled two class-action lawsuits by game artists and programmers for about $15 million each. The Activision suit is still pending.

Zynga has made efforts to change its ways. The company has added data centers and expanded teams to ease the burden on its engineers. It is also encouraging managers to schedule a bigger buffer between project phases and to give teams the week off before a game’s debut. Zynga — which offers employee perks like acupuncture, Friday happy hours and a cafeteria with organic food — is also spending millions on focus groups and other initiatives to strengthen its manager training programs.

Mr. Pincus is also trying to soften his managerial style. Ms. McCreary has spent significant time with the executive, coaching him on his tone and constructive criticism. In 2010, the company also hired an outside consultant to do a “360-degree review” of Mr. Pincus. The consultant interviewed employees and board members and produced a report filled with feedback.

Still, rivals say Zynga will have to do more to bolster its image, or risk losing its appeal as an employer at a time when resources are scarce. Zynga’s towering public valuation — a boon for investors — may only further dissuade recruits, who may turn to younger start-ups with more potential.

“We’ve learned that when companies treat talent as a commodity, the consequences are severe,” said Ms. Toledano of Electronic Arts. “It takes years to repair a reputation.”