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Use of antipsychotics in Maine nursing homes climbs

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Use of antipsychotics in Maine nursing homes climbs


Sherri Parker, assistant director of nursing at Caribou Rehab and Nursing, recalled a woman who came to her facility and was so sedated by the prescribed antipsychotic medication she had been taking at home that they couldn’t keep her awake for therapy because “she’d fall asleep in front of you.”

Parker, who handles gradual dose reductions at the nursing home, said she worked with a doctor to wean the woman off the medication. By the time the resident transferred back home two months later, “she was a completely different woman,” Parker said — able to eat on her own and be home alone while her husband went to work.

“I’ve seen a stopped antipsychotic medication on many people and sometimes I’m like, ‘Wow, they’ve actually done really well.’ That just goes to show me that it really wasn’t necessary to keep them on that,” Parker said.

But in recent years, she has seen an increase in these medications. At the end of last year, while reading referrals from the hospital for new residents, Parker said nearly every one had a prescription for an antipsychotic medication. She said it’s likely they were prescribed the medication while living at home or when they went to the hospital before ending up at her nursing home.

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Statewide data shows the percentage of Maine nursing home residents receiving antipsychotic medication is increasing.

While the rate for short-stay residents, like the one Parker recalled, is relatively low, Maine’s rate for long-stay residents is higher than the national average. Short-stay residents are in a nursing home for less than 100 days, often recovering from surgery or being discharged from a hospital, according to the U.S. Centers for Medicare and Medicaid Services.

In the years after federal regulators cracked down on rates of antipsychotic medication given to long-stay nursing home residents, Maine became a success story, dramatically reducing its rate between 2011 and 2017 from 27 to 17 percent.

But since then, Maine’s rate has crept back to 20 percent, higher than the national average of 14.7 percent and the sixth-highest across all states, according to the U.S. Centers for Medicare and Medicaid Services. Among all American adults, the rate of antipsychotics was less than 2 percent. 

Antipsychotics are a type of medication, including Risperdal and Seroquel, designed to manage psychosis and delusions. They’re often given to patients with a diagnosis of schizophrenia or bipolar disorder. The side effects can be severe, including tremors, heart and circulatory problems, high cholesterol and sedation. They can be particularly problematic for older adults, even potentially shortening the lives of nursing home residents by increasing the risk of drowsiness, confusion and falling, said several experts.

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CMS data on nursing home rates of antipsychotics exclude people diagnosed with schizophrenia, Tourrette’s Syndrome and Huntington’s Disease.

“Antipsychotic medications are especially dangerous among the nursing home population because of their potentially devastating side effects, including death, and the use of antipsychotic medications among nursing home residents is an indicator of nursing home quality,” a CMS spokesperson told The Maine Monitor.

Treating an episode, not a behavior

Dr. Susan Wehry, associate clinical professor at the University of New England in Biddeford and a board-certified geriatric psychiatrist, said there are times when antipsychotic medications are necessary to prevent a resident from harming themselves or others, but those occasions are rare.

“I understand an acute need for using a chemical restraint, but call it what it is: This is not treating a behavior; this is treating an episode of agitation that you can’t figure out how to address another way,” Wehry said. “You’re basically sedating the person.”

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Wehry said what is often depicted as challenging behaviors from residents with dementia is actually the resident trying to communicate an unmet need. They may not have the language to say what they want, so rather than sedating the resident, it’s important to find out the cause of their frustration, she said.

Parker, with Caribou Rehab and Nursing, said she’s seen residents come off these medications and become more alert, social and talkative. And sometimes there’s no change in behavior, which she said begs the question why the resident needed to be on the medication in the first place.

As of this month, roughly 19 percent of Caribou Rehab and Nursing residents were on antipsychotics, slightly below the statewide average. Parker recalled when their rates were 5 percent and how proud she was, but said the numbers can fluctuate as admissions come in with pre-existing prescriptions.

“I tried really hard with my antipsychotic numbers to be down, and then just slowly they crept up again as we took admissions,” Parker said. “I would love to see my numbers come down and I know those are some things we have to work on.”

Multiple experts and advocates point to a number of explanations for Maine’s rising statewide average, such as staffing shortages and reliance on temporary agency staffing, diminished attention to the problem, MaineCare underfunding for nursing homes, and the all-consuming nature of the COVID-19 pandemic, which demanded more attention on infection control.

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Staff who are overwhelmed with duties or haven’t had time to build relationships with residents may turn to medication rather than spending time on de-escalation techniques when residents have challenging behaviors.

“It’s a disappointment to see the rates have increased because I know we can do better,” said Brenda Gallant, Maine’s long-term care ombudsman who advocates for nursing home residents and their families.

Gallant was part of the coalition in 2012 that led the effort to reduce Maine’s rates of antipsychotics, with Wehry and numerous other advocates, providers and organizations.

Multiple people involved in that effort said the success was due to the commitment of a broad coalition that involved statewide trainings, workshops, mentoring programs, grants for innovative programs like Music and Memory, and resources such as a handbook for providers.

The guidance urged providers to take a holistic approach to treating dementia patients, which included education for family members on the risks associated with the medication, staff training programs that identify specific areas of competency and a collaborative transition process with hospitals.

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“Initially, we were leaders,” Gallant said, adding that at one point Maine was ranked the seventh-most improved state in 2016, according to federal data cited at the time by the Maine Partnership to Improve Dementia Care in Nursing Homes.

Nationally, the rates during that time decreased from about 24 percent in 2011 to 14.3 percent in 2019, while Maine’s crept back up. But this data also can lag slightly: the collection period for the current data on this quality measure was Oct. 1, 2022 to Sept. 20, 2023.

“The tip of the iceberg”

In recent years, some experts have become concerned about an overreliance on medication for older adults, including Dr. Jabbar Fazeli, who has served as medical director for multiple nursing homes and assisted living facilities in Maine. He said antipsychotics could be the “tip of the iceberg,” and that facilities also use mood stabilizers and sleeping pills as a way to sedate residents.

Fazeli served as co-chair of the Maine Partnership to Improve Dementia Care in Nursing Homes and has been outspoken about reducing overreliance on medication for older adults. Before the federal government decided to focus on the issue, it was difficult to push back against a “pervasive” culture of using antipsychotic medications, Fazeli said.

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Durgin Pines in Kittery, where Fazeli served as medical director for more than a decade until last month, maintained a rate of antipsychotic medication that was always below 5 percent, he said. Currently the facility has a rate of 4.2 percent, according to the Centers for Medicare & Medicaid Services. Fazeli said the success was dependent on a joint effort with the director of nursing, assistant director of nursing and the administrator to try all other options before resorting to an antipsychotic medication.

In recent years, lawmakers and the federal government have also become concerned about nursing homes “erroneously” claiming residents had schizophrenia as a way to “mask the facilities’ true rate of antipsychotic medication use,” the agency said in a release last year. CMS conducted onsite surveys to look at schizophrenia diagnoses and conducted audits of how nursing homes coded these residents.

An oversight organization said this does not appear to be a problem in Maine. The nonprofit that provides quality improvement organization services in New England, Healthcentric Advisors, said it has “thoroughly analyzed” Maine data and determined the state is not seeing an increase in schizophrenia diagnoses.

Fazeli added that in his 26 years in geriatric care, Maine is better than most other states, including those he worked in like Missouri, Massachusetts, Connecticut and New Hampshire.

Sherri Parker, of Caribou Rehab and Nursing, said she’s seen residents come off antipsychotics and become more alert, social and talkative. Photo by Paul Cyr for Caribou Rehab and Nursing Center.

But after a lot of initial energy in Maine, attention on the issue slowed, especially during the pandemic, Gallant said.

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Many said the pandemic was all-consuming for nursing home providers, making it difficult to keep the focus on reducing antipsychotics while keeping up with evolving regulations and caring for residents who were forced to be quarantined.

Wehry, the geriatric psychiatrist, said it was understandable for rates to climb back up in the first months of the pandemic, but “that’s no longer an adequate excuse.” She said a lot of nursing homes reverted back to institution-centric care that forces residents to conform to their environment rather than create an environment that works for them.

“I think it’s broader than just the individual person who’s getting the antipsychotic. I think the culture change, which people worked so hard to introduce, also backslid in the pandemic,” Wehry said.

Ruta Kadonoff, who worked for the national nursing home industry group during the 2012 effort to reduce antipsychotic medication, and traveled across the country providing education on the issue, said Maine’s biggest challenge is workforce shortage.

Staff need adequate training on how to “get inside the world of a person with dementia,” time to work with a resident who is upset or struggling to communicate a need, and support to provide person-centered care that allows them to build relationships with residents. None of that is possible in a facility that is understaffed, has high turnover or relies on temporary agency staffing.

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“Until we address that, I don’t think it’s realistic to think we’re going to address other quality issues,” Kadonoff said. “It’s a bandaid to try to address other things without dealing with the underlying fact that we just don’t have the people to provide this care and to do it well.”

Healthcentric Advisors, the quality improvement organization, said it has been meeting with the long-term care ombudsman and the Maine Health Care Association, which represents the state’s nursing homes, about refocusing attention on this issue. They plan to update and reintroduce training modules that condense the most useful tools and resources, which will be rolled out in late fall.

The Maine Department of Health and Human Services said it has identified the increasing use of antipsychotics in nursing facilities and encouraged the stakeholder group to reconvene along with nursing facilities administrators and medical directors. In January, DHHS published a stakeholder group report, Improving Quality in Maine’s Nursing and Residential Care Facilities, and noted that “this metric is likely to be among those tied to reimbursement as part of nursing home payment reform,” spokesperson Lindsay Hammes said.

Gallant, the ombudsman, said it’s important to return attention to this problem “if we want to make progress and get back to the place that we had initially in terms of really being leaders. I think that should always be our goal: to do the very best that we can for residents in our nursing homes.”





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Maine Bowling Alley Reopens 6 Months After Mass Shooting: 'The Community Has Been Phenomenal'

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Maine Bowling Alley Reopens 6 Months After Mass Shooting: 'The Community Has Been Phenomenal'


The Lewiston, Maine, bowling alley where a mass shooting occurred in October has reopened, reports the Associated Press, The Washington Post and New York Daily News.

Justin and Samantha Juray, owners of Just-In-Time Recreation, opened the doors of the venue on Friday, May 3, six months after the state’s deadliest shooting that killed 18 people and injured 13. 

Gunman Robert Card killed eight people at the Jurays’ bowling alley and then drove to a nearby bar, Schemengees Bar and Grille, and killed 10 more people. He later died by suicide. 

“It’s never going to leave my head,” Samantha, 34, said, per AP. “I think if we don’t move forward — not that there was a point to this whole thing anyway — but we’re just going to allow the people that have taken so much from us win.”

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Still, Justin, 43, said he was hesitant about reopening the bowling alley —that was until the Lewiston community supported the pair.

Kathy Lebel, owner of Schemengees Bar & Grille, also hopes to reopen her establishment but at a different location.

Lewiston bowling alley on Wednesday, May 1, 2024, in Lewiston, Maine. (.

AP Photo/Robert F. Bukaty


Several patrons attended the reopening, including people like Colin, who was at the bowling alley the night of the mass shooting. Colin went to Friday’s event with his mother and father, John Robinson.

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“I can’t say how great this day is,” Robinson said, per AP. “An opportunity to celebrate their lives. To celebrate the rebirth of Just-In-Time.”

Employee Tom Giberti also told the outlet that people are “so excited to get us back.”

“The community has been phenomenal,” he said. “They’ve been right here for us, they’ve been supporting us.”

Giberti, 70, is one of the heroic community members who saved the lives of at least four children that day. Before he could get himself to safety, he took the children between the lanes to an area behind the bowling pins. 

He was shot in both legs a total of five times and hit with shrapnel. He underwent surgery and now shows very few signs of his injuries, according to AP.

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Police presence at Schemengees Bar where a mass shooting occurred in Lewiston, Maine on October 26, 2023.

JOSEPH PREZIOSO/AFP via Getty Images


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Among the eight people who were killed were two Just-In-Time staff members. A majority of the staff have returned to work.

The bowling alley honored those who died by displaying photos of the eight people who lost their lives at Just-In-Time, and bowling pins with the names of the 18 shooting victims behind the front desk.

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Additionally, the Bowling Proprietors’ Association of America gave the venue a new scoring system, new automatic bumpers, and gutters. It also provided a seasoned expert who fixes bowling machines to spend a week at the site, per The Washington Post.

There was also a ribbon-cutting ceremony on Friday afternoon, with Lewiston Mayor Carl Sheline celebrating the reopening. “This is us, standing back up again,” said Sheline. “With all of you here, it’s very clear. Lewiston can never be kept down.”

“You’re the reason,” Justin added. “This is why. This is why we decided to reopen.”



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College graduations begin in Maine as protests disrupt ceremonies in other states

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College graduations begin in Maine as protests disrupt ceremonies in other states


Israel Palestinians Campus Protests

Student protesters camp near the entrance to Hamilton Hall on the campus of Columbia University, Tuesday, April 30, 2024, in New York. Early Tuesday, dozens of protesters took over Hamilton Hall, locking arms and carrying furniture and metal barricades to the building. Columbia responded by restricting access to campus. AP Photo/Mary Altaffer, Pool

Maine colleges and universities are preparing to graduate thousands of students in the coming weeks at the same time protests over Israel’s war in Gaza have disrupted commencements and other campus activities  around the country.

School officials in Maine said they can’t share specific public safety planning details, but there’s no indication they expect problems at upcoming commencement ceremonies.

Students on Maine campuses have taken stands against the war, including by holding protests and calling on their schools to divest from defense funds. Events and efforts to speak out are ongoing and generating some tensions with administrators over the role of the institutions in calling for peace.

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Around the country, college campuses have been upended the last few weeks by protests.

Police arrested nearly 300 people on two college campuses in New York City Tuesday — Columbia University and the City College of New York — though many of them were not affiliated with the schools, CNN reported.

The University of Southern California has cancelled its main graduation ceremony due to protests, and other campuses are implementing additional security measures in anticipation of potential disruptions.

UMAINE PREPARED WITH SECURITY 

The current war in Gaza began Oct. 7, when Hamas militants crossed the border from Gaza into Israel and killed about 1,200 people and took roughly 250 hostages in a surprise attack. Israel launched a counter offensive that has killed more than 34,000 Palestinians in the Gaza Strip, according to the Health Ministry there.

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Protests against Israel’s offensive have intensified on college campuses in recent weeks. Maine campuses haven’t experienced the same level of unrest as other places, though there has been some activity. A protest at the University of Southern Maine last week drew about 30 people for a peaceful demonstration that did not result in any arrests.

The University of Maine System begins holding commencements this weekend. It has 6,175 students who are eligible to receive their degrees or certificates from universities this month, though not all will participate in graduation.

The flagship campus in Orono, where undergraduate students will graduate Saturday, has 2,800 students eligible to graduate and 2,100 expected to participate in ceremonies. The University of Southern Maine, which will also hold commencement Saturday, has 1,635 students eligible to graduate and expects 1,063 to participate in the ceremony at the Cross Insurance Arena in Portland Saturday morning.

Meanwhile, the group Maine Students for Palestine is encouraging students and community members to participate in a rally and march to be held at 1 p.m. in Deering Oaks.

“We stand united in our call for international solidarity among all members of the global working class to help stop the ongoing genocide in Palestine,” Maine Students for Palestine said on Instagram. “Money for jobs and education, NOT for war and occupation!”

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Dan Hartill, a spokesperson for USM, said in an email Friday that no problems are expected at Saturday’s graduation ceremony.

Samantha Warren, a spokesperson for the system, said she could not share specific public safety planning details but that given the size of graduations, university public safety officials always partner with local and state authorities to ensure the safety of graduates and attendees.

Warren said this weekend’s graduations mark an important milestone for graduates, most of whom missed the opportunity to have an in-person graduation at their high schools because of COVID-19 in 2020. “This weekend should be all about honoring our graduates,” she said.

Some University of Maine System students have also made calls for the system to divest from holdings in companies they say are involved in conflicts in the Middle East.

Warren said the system does not directly buy or sell securities, but works with professional advisors who assist the Board of Trustees’ Investment Committee in selecting appropriate fund managers.

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She said the system and its advisors have identified the 12 companies students asked about at an April Board of Trustees meeting and they account for $1.6 million, or 0.22%, of the system’s $717 million total investment portfolio.

“The Board will continue to listen to and welcome student perspectives,” Warren said in an email. “As is its fiduciary responsibility, the Board’s Investment Committee routinely reviews the System’s portfolio to ensure assets are being invested and managed in a manner that maintains and grows principal and generates earnings that can be reinvested directly to benefit our students, employee pensions, and public university programs and campuses.”

COLBY, BATES, BOWDOIN SEE NO MASS PROTESTS 

So far, no mass demonstrations or encampments have popped up at Maine’s top three private colleges, but students at Bowdoin and Colby are calling on their respective colleges to divest from funds that support Israel’s war in Gaza.

Bowdoin students are voting through Saturday afternoon on a referendum urging the college to speak out against “the Israeli government’s ongoing scholasticide in Gaza,” referring to the destruction of academic institutions and killings of students, educators and parents. The referendum is nonbinding, according to a college spokesperson.

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Spearheaded by the Bowdoin Students for Justice in Palestine, the “Bowdoin Solidarity Referendum” also calls on the college to disclose its investments in arms manufacturers, halt future investments in the defense industry, and reinstate an independent committee of students, faculty and staff to oversee social responsibility in future investments.

Bowdoin President Safa Zaki sent an email to students opposing the referendum, expressing concerns about the college taking sides in the controversy and how the proposed investment restrictions could negatively impact the college’s endowment.

“My belief, which I have shared previously, is that institutional statements often divide communities, harden divisions, and interfere with the free exchange of ideas central to an academic community,” Zaki said in the letter posted to the school’s website.

Members of the faculty, meanwhile, wrote a letter published by the Bowdoin Orient in support of students’ rights to protest and condemned actions by other campuses to suppress demonstrations through arrests and suspensions.

“We affirm the university as a space of freedom of association and assembly, freedom of thought and expression and a site of dissent,” stated the letter, signed by more than 80 faculty. “We note, with appreciation, that Bowdoin has not pursued these tactics against Students for Justice in Palestine (SJP) organizers and supporters.”

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Bowdoin spokesperson Doug Cook said in an email the college has not seen any public demonstrations on campus and is not worried about any disruptions at its May 25 graduation or other year-end events.

A similar call to action was issued to Colby College.

On Monday, a group calling itself “Colby Action for Palestine” called on the college to cut ties with Israel, including opportunities to study abroad, and divest from any interests that benefit Israel’s occupation of Gaza.

The group demanded that Colby “end its complicity in the present and long-term oppression and genocide alike of the Palestinian people at the hands of the State of Israel.”

However, school officials noted that the email was sent from an address from outside the college, so it’s not clear whether it came from students or not.

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Colby President David Greene said in a letter to the community that the college has “no intention of simply acquiescing to threats and arbitrary deadlines from an anonymous group.” He said the college will continue to support students’ rights to peacefully protest but would not tolerate hate speech or harassment.

Colby spokesperson George Sopko echoed that position when asked whether officials were worried about possible disruptions at the college’s graduation ceremony on May 26.

“The members of the Colby community have the right to engage in peaceful protest and awareness raising as long as those events comport with our policies and do not interfere with the academic or operational activities of the College,” Sopko said.

And at Bates College, spokesperson Mary Pols said no protests or encampments have popped up on campus.

“Bates recognizes and supports the right of individuals or groups on our campus to protest peacefully, without disrupting the normal operations of the college,” Pols said. “Bates retains the right, recognized by law, to regulate the time, place, and manner of protests.”

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ENCAMPMENT AT COLLEGE OF THE ATLANTIC

At the College of the Atlantic in Bar Harbor, students set up an encampment on Sunday with about 30 tents to express support for the people of Palestine and for staff and students at other universities who are encountering violence for their stance on the war.

Student organizers declined a request for an interview Friday, but shared a statement from the COA Palestine Solidarity Encampment.

The group said it is asking the college to publicly denounce the genocide of the Palestinian people, disclose its investments and prioritize divestment from all weapons manufacturing, surveillance and technology and construction companies that are profiting from the killing of Palestinian people.

“As students at an educational institution in the U.S. we feel the responsibility to protest the bombing and demolition of schools and colleges in Gaza,” the statement said. “Access to a demilitarized education is a human right for all.”

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College of the Atlantic President Darron Collins said in a statement that the administration supports students’ rights to engage in protest and free speech though the university has asked students to prioritize safety and cleanliness of the encampment and said that any form of hate speech will not be tolerated.

Regarding divestment, Collins said that questions about investments are ultimately decided by the school’s Board of Trustees. Students taking part in the encampment met last week with the school’s chief financial officer to discuss the topic and have also been invited to join the trustees’ Investment Committee meeting next week, he said.

Because the college runs on trimesters, its graduation is not until June 8. Rob Levin, director of communications, said it’s too early to say if the encampment will impact graduation plans but said the college is trying to work with the students who are involved.

“We support our students’ rights to express their free speech and their political expressions,” he said. “We’re trying to take that collaborative approach.”

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Portland Weather | News, Weather, Sports, Breaking News

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Portland Weather | News, Weather, Sports, Breaking News


SEARCHING FOR SUN

That early May sun should burn off low clouds during the course of the day supplying most of the region with the return to a little bit of sun. Temps will be warmest over the interior. That’s going to be common theme through the weekend as onshore winds will keep temps coolest at the coast. Expect a mix of sun and clouds to start out the weekend with our next round of rain developing late Sunday. Warmer temps will make a return to the region early next week.

Charlie Lopresti-Chief Meteorologist

FRIDAY: Cloudy start. Becoming partly sunny. Highs in the upper 50s and low 60s. Coolest at the coast. E winds 5-10 MPH.

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FRIDAY NIGHT: Becoming cloudy with areas of fog. Lows in the low 40s.

SATURDAY: Clouds and sun. Highs in the 50s.

Track storms using our Interactive Radar

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Do you have any weather questions? Email our Weather Authority team at weather@wgme.com. We’d love to hear from you!



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