Rotator cuff injuries common but easily remedied

Most rotator cuff injuries are easily remedied and many are even preventable, according to a University of Alberta rehabilitation medicine researcher.

“Over time, the rotator cuff tissue wears out, so the longer you can kind of keep everything mobile and strong, the better,” said physical therapy professor Judy Chepeha. “For that to happen, we need to look at overall shoulder health and a really good balance of muscles.”
Chepeha likens the rotator cuff to a hand coming from the shoulder blade to the front and grabbing onto the ball at the top of the upper arm.
“Four muscles converge together to form this common attachment really deep within the shoulder joint, to stabilize the joint while allowing the arm to rotate,” she said. “You can see why, when it goes down, there are some pretty big consequences.”
Before anyone finds their way onto the rotator cuff injury spectrum, Chepeha said strengthening the muscles along the shoulder blade, as well as the trapezius—a set of three postural muscles that span the entirety of the upper back—can help.
“The rotator cuff lives on the shoulder blade, so the two are absolutely partners in this,” she said. “Strong shoulder blade muscles equal a good environment for a strong cuff.”
Chepeha’s suggested exercises for strengthening the shoulder and back complex include movements and exercises along the lines of shrugs, rowing and lat pulldowns.
“Anything where you squeeze your shoulder blades together is great,” she said.

Most people think rotator cuff injuries are a result of a major episode, such as a “fall on an outstretched hand”—known as a FOOSH injury—where the joint gets compressed and torn. But Chepeha said more often than not, injury comes as a result of repetitive strain. People whose vocation includes tasks done above shoulder height, such as carpenters and painters, are particularly vulnerable, as are athletes.
“We see that one-mechanism rotator cuff injury for sure, but mostly when we put the puzzle pieces together, we realize there’s been a lot of stress on that tissue,” she explained.
Repetitive motion over time can result in inflammation and even minor partial thickness tears, which Chepeha said sound terrible but can be remedied quite well with time and exercise, and rarely require surgery.
In rehabbing such injuries, she said patients will want to follow the same guidelines as for any other injury—modified rest followed by activity.
“What we really try and get people to do is to move within their pain-free range as soon as they can,” she said. “If you do nothing because you’re scared to move your shoulder, it will adhese or stiffen up, and can lead to a frozen shoulder.”
She explained a favorite rehab exercise of most physiotherapists involves the patient holding their arm at their side with a 90-degree bend at the elbow. They then simply rotate their forearm and wrist inwards and out.
Chepeha noted that shoulder management is very active and doesn’t involve a lot of the physio machines patients may come to expect with other injuries. She added she likens shoulder rehabilitation to strengthening your core.
“I always talk about that area as the upper core of your trunk: the shoulder blade muscles help bring you out of that rounded forward position and the cuff helps stabilize the shoulder joint so we can move our arms efficiently.”

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https://medicalxpress.com/news/2020-01-rotator-cuff-injuries-common-easily.html

Experts fear too late for China virus lockdown

China’s bid to contain a deadly new virus by placing cities of millions under quarantine is an unprecedented undertaking but it is unlikely to stop the disease spreading, experts warn.

The contagious virus has already reached elsewhere in China and abroad, and even an authoritarian government has only a small timeframe in which trapped residents will submit to such a lockdown, they say.
“I think we have passed the golden period of control and prevention,” said Guan Yi, an expert on viruses at Hong Kong University.
China began its campaign on Thursday, cutting off all transport links out of Wuhan, a city of 11 million people where the coronavirus linked to SARS emerged late last year.
A cascading number of nearby cities has since been added to the travel blacklist, corralling more than 40 million people in a bid to stop those with the disease travelling and infecting others elsewhere.
However, with the death toll at 26 and infections being detected as far away as the United States, there are fears the exercise is too little too late.
Yi, who returned from Wuhan just before the lockdown, pointed out huge numbers of people would have already left ahead of the Lunar New Year holiday, which began Friday.
They could have been incubating the virus “on their way out of Wuhan”, he said.
Symptoms could take several days to emerge—effectively seeding a health time-bomb across the country and abroad.
Escape plans
Meanwhile, new gaps in the security web in Wuhan and its surroundings will likely emerge over coming days, even as China deploys its formidable security forces.
They are manning road blocks that have been set up, while train and plane services have been suspended.
“Especially people with money and connections, they’re going to make a run for it… and they’ll probably be successful,” Zi Yang, a senior analyst at the S. Rajaratnam School of International Studies in Singapore, told AFP.
University of Sydney associate professor Adam Kamradt-Scott, an expert in global health security, said only a “handful” of countries could conceivably pull off the mass quarantine.
He suggested the US was one of the few that may be able to mount a similar operation, using the National Guard, although it would face much stiffer opposition from a population accustomed to more civil liberties.
China’s communist rulers draw on a deep well of public acquiesence—partly due to control of the internet, no free press and a brutally efficient security apparatus.
“I can’t imagine there would be too many countries that would be able to do something on this scale as quickly as China has done,” Kamradt-Scott said.
Even so, Kamradt-Scott warned a lockdown that extends for a week or more would produce “growing levels of discontent and frustration”.
“The Chinese authorities will be conscious of that, I’m sure, and they’ll be monitoring it very closely to avoid the risk of any sort of social unrest,” he said.
Quarantine ‘illusion’
Kamradt-Scott said that, even though the virus would inevitably spread, the quarantine appeared designed to buy authorities time to put in place other measures.
He cited China’s plans to build a 1,000-bed hospital in Wuhan in just 10 days.
Zi, from the S. Rajaratnam School, also said there was some hope the quarantines would have a level of success in containing the outbreak.
“I believe it is possible given China’s expertise in this area of population control, or urban control,” Zi said.
Yet the history of quarantine suggests controls will be far from watertight.
The concept emerged in Venice in the 14th century, where ships arriving at the city state from infected ports were held offshore for 40 days.
Over the centuries the US attempted quarantines to combat yellow fever, European nations tried to subdue cholera outbreaks, and several West African nations sealed off townships to hem in Ebola in the last decade.
Quarantine is “purely an illusion”, said Bruno Halioua, a historian of medicine at the University of Paris IV.
“Quarantine has never worked. Each time, there have been problems.”
And after seeing the situation in Wuhan first-hand, Guan Yi of Hong Kong University shared an equally pessimistic outlook.
“I’ve never felt scared,” Guan said. “This time I’m scared.”
https://medicalxpress.com/news/2020-01-im-experts-late-china-virus.html

US to evacuate citizens from Chinese city amid spread of coronavirus

The U.S. government is reportedly preparing a charter flight this weekend to evacuate American citizens and diplomats from Wuhan, China, the epicenter of the latest coronavirus outbreak.
The Wall Street Journal reported on the plans Saturday, citing a person familiar with the operation. The expected flight on Sunday comes as the death toll from the illness stretches to more than 40 and the number of confirmed cases continues to rise around the world.
The consulate in Wuhan is reaching out to the estimated 1,000 American citizens in the area to offer them a seat on the jet, which seats about 230, according to The Journal. Those evacuated will pay the financial cost of their ticket.

The passengers on the jet, a Boeing 767, will include diplomats from the U.S. consulate, Americans and their families, and medical personnel aboard to ensure that anyone infected with the virus is cared for.
The person familiar with the plan confirmed that any additional seats could be given to non-U.S. citizens, including diplomats of other nations, and that the U.S. intends to temporarily shutter its Wuhan consulate.
The operation was reportedly approved by China’s Foreign Ministry and other government agencies.
Neither the Wuhan consulate nor the State Department immediately responded to requests for comment from The Hill on Saturday.
Beyond the Chinese mainland and Hong Kong, Australia, Malaysia, France and the U.S. have all reported confirmed cases of the coronavirus, raising fears of an international outbreak.
More than 1,300 people have been infected globally, according to tallies, with the majority of the cases occurring in China.
https://thehill.com/policy/healthcare/479886-us-to-evacuate-citizens-from-chinese-city-amid-spread-of-coronavirus-report

Gottlieb: What must be done to head off the coronavirus threat

Scott Gottlieb, a resident fellow at the American Enterprise Institute, was commissioner of the Food and Drug Administration from May 2017 to April 2019. He consults for and invests in biopharmaceutical companies.

Health authorities’ concern about the new coronavirus in China, with cases spreading in Asia and as far as the United States, deepened Wednesday with news that the Chinese government plans to shut down transportation from Wuhan, a city of 11 million people that is considered ground zero of the pneumonia-like virus.

After the outbreak began in December, the Chinese government for weeks portrayed it as a problem largely restricted to Wuhan, in the Hubei province. Infections have since been found in the Chinese territories of Hong Kong and Macao, and in South Korea, Japan, Taiwan — as well as in this country in Washington state. Of particular concern: The news Monday that Chinese authorities had determined that the virus can be spread by human-to-human contact, and that 14 health-care workers had been infected by a single carrier. As of Wednesday, 17 people have died and more than 470 have fallen ill with the virus, The Post reported.

China’s seeming reluctance to share information in the early stages of the outbreak slowed the international recognition of the threat. A turning point came when video footage surfaced earlier this month showing Chinese health authorities — clad in full-body protective suits — examining passengers on an airplane. The earlier secrecy raises doubts that China has fully learned key public health lessons since the SARS virus killed nearly 800 people in 2003 and then MERS claimed some 850 lives a decade later.

This time, the world is better prepared to deal with the threat. Though the warning signs are unsettling, there is reason to believe that the virus may mostly cause mild illness and can be contained without major impacts. But how it unfolds will turn on some critical questions and on actions that still need to be taken.

As with the MERS and SARS viruses, the Wuhan pneumonia is caused by a novel coronavirus that jumped from animals to people. Poor animal husbandry in open food markets make China an epicenter for these risks. Wuhan’s bazaar sells freshly slaughtered animals — including chickens, pheasants, marmots, snakes, deer and rabbits. These “wet markets” create perfect conditions for viral species to spread from their animal hosts to humans.

Coronavirus is a species implicated in bad colds and, on rare occasion, viral pneumonia. Seven strains are already known to circulate among humans. The bug behind the Wuhan outbreak is new, which makes its emergence a cause for significant concern. Humans may not have much immunity to its main components.

By some measures, Chinese health authorities have put us ahead in addressing the risks. Unlike SARS, which took about five months to firmly identify after it first began to spread, the Wuhan virus has been quickly sequenced and large-scale containment efforts were implemented early. China has already made diagnostic tests available to its health-care system.

Yet, on other measures, more-seamless information-sharing by Chinese authorities is needed. They published the sequence of the viruses they had isolated, but China doesn’t appear to have shared viral samples with key international health authorities who could have used the pathogen to help validate diagnostic screening tests and evaluate potential antidotes.

It is now up to other countries to work together on steps to avert wider outbreaks or pandemic spread.

First, we need to better understand the nature of this bug, and its severity. The illness may be more widespread than we realize in the fog of viral war. Because its incubation period is likely to be as much as a week, travelers can be harboring the infection and show no symptoms. A key to containing the virus’s wider spread will be developing effective point-of-care diagnostics to implement more widespread screening of patients.

We learned that lesson with the mosquito-borne Zika virus when it was first reported in the United States in 2015. Initially, most blood samples had to be shipped to a central lab operated by the Centers for Disease Control and Prevention. That slowed diagnosis and limited the ability of doctors to intervene more quickly when patients were infected. Health-care providers urgently need easy access to effective diagnostic tests for the Wuhan virus.

There’s much we don’t know yet, but answers should emerge that will help us gauge the risks. It’s troubling that the virus seems to have jumped quickly from animal to human transmission. But, for most people, it might cause only a mild illness. For the young, old or infirm, an infection could be more serious.

Yet even if it the Wuhan virus doesn’t mutate into a more potent illness, as it could, it’s a disturbing reminder that we remain too vulnerable to these zoonotic threats, as illnesses that spread from animals to humans are known. One day, a virus will occupy the terrifying spot where lethality and dissemination meet. It will be nimble enough to propagate widely and virulent enough to cause catastrophic harm. The Wuhan episode shows that while we’ve learned some lessons from SARS and MERS, we remain tragically vulnerable.

https://www.washingtonpost.com/opinions/2020/01/23/world-is-better-prepared-coronavirus-threat-we-remain-tragically-vulnerable/

Formulary tool aims to help payers get early info on drugs pre-approval

A formulary submission tool has been updated to enable payers to get access to drugs’ product information before they are approved in order to make decisions faster.
The Food and Drug Administration (FDA) gave greater flexibility to drugmakers in 2018 to share information on unapproved products with insurers and formulary managers. The Academy of Managed Care Pharmacy (AMCP) updated its format for formulary submissions to include new ways for drug companies to share information on unapproved products.
The AMCP format is traditionally used by drug companies to create a dossier for payers to help them decide whether to cover a product on their formulary. The dossier contains information on the safety and effectiveness of the drug.

The format was updated in late December to include ways for drug companies to voluntarily share information with payers on products that are about 12 to 18 months away from FDA approval.

AMCP wanted to address a growing trend among drug manufacturers.
“We have seen biopharmaceutical companies that have begun to share information about a product’s pre-approval,” said Cindy Reilly, senior vice president for the academy. “What the dossier does for the first time is it provides a standardized format in terms of how that information is created.”
The FDA released final guidance back in June 2018 that details how drug companies can share information on unapproved products.
Payers want to know information that includes efficacy, safety and cost-effectiveness of approved products. By getting this information earlier, they can help outline their budget for pharmaceutical spending, Reilly said.
“One of the key things that healthcare decision-makers want to know is what is the expected indication, which helps figure out the expected population and helps them budget,” she said.
The new format comes as insurers have struggled with how to deal with rising pharmaceutical costs.

Insurers have increasingly adopted formulary management tools such as prior authorization that require approval from the insurer before a doctor can prescribe pricey treatments.
However, the shift toward prior authorization has increased costs on physicians. A recent study from the Council for Affordable Quality Healthcare (CAQH) found that the costs to manually generate a request to insurers for prior authorization for a prescription went up 60% in 2019.
Reilly said that as more insurers move toward prior authorization, there are efforts to move requests to insurers electronically. This way a physician wouldn’t have to use manual processes like a fax machine.
But the CAQH study found that overall industry use of electronic prior authorization only rose slightly to 13% in 2019, up from 12% in 2018.
https://www.fiercehealthcare.com/payer/newly-updated-formulary-tool-hopes-to-help-payers-get-early-information-unapproved-drugs

Coronavirus patients arrived in France without symptoms

Two of the three Chinese nationals in France who have been diagnosed with the Wuhan coronavirus arrived without showing symptoms, doctors at a Paris hospital said on Saturday.

On Friday, France confirmed the first three cases of the virus in Europe, with two patients hospitalized in Paris and the other in Bordeaux. The health ministry said on Saturday that no new cases have been confirmed since then but several people were being monitored.
In China, 41 people have died from the virus and more than 1,400 people have been infected globally, including four in Australia and three in Malaysia.
The two patients in Paris are a Chinese couple who arrived in France on Jan. 18 but did not show symptoms until Jan. 19 and 23 respectively, officials said.
“They showed no symptoms when they boarded their plane,” Yazdan Yazdanpanah, head of infectious diseases at Paris hospital Bichat told reporters.
The third patient, in Bordeaux, a 48-year old Chinese man who works in the French wine industry, had taken a plane from Wuhan to the Netherlands and entered France from there, SOS Medecins medical service in Bordeaux said.
Health Minister Agnes Buzyn told reporters the man had entered France on Jan. 22, had first consulted a doctor about his symptoms on Jan. 23, and had been diagnosed with the virus on Jan 24.
The delayed appearance of symptoms and the entry via a third country underline the limits of screening passengers arriving from China in airports.
Airports in several countries are using scanners to take the temperature of passengers arriving from China but France so far is not doing this. Passengers arriving on flights from China told BFM TV that they had been subject to no controls whatsoever upon entering France.
In Paris, there was a rush to buy face masks, and several pharmacies said they were sold out.
“It has been like this since this morning, some people are hysterical,” said a pharmacist in Paris.
The French foreign ministry said on Saturday it was looking at options for French nationals to leave Wuhan, which has been in virtual lockdown since Thursday, with nearly all flights canceled and checkpoints blocking the main roads.

On Friday, it said it had planned to set up a bus service to help them leave.
French automotive group PSA, maker of the Peugeot and Citroen brands, said it will repatriate expat staff and their families – a total of 38 people – from the Wuhan area.
https://www.reuters.com/article/us-china-health-france/coronavirus-patients-arrived-in-france-without-symptoms-idUSKBN1ZO0NB

How To Overcome Major Life Setbacks

A few years ago, I met with a portfolio manager who had a long track record of success. He had built a large position in the stock market, but felt that the market had perhaps gotten ahead of itself in the short run. As a result, he hedged his position with a second large position in volatility instruments. The idea was that if the market went down, this would likely occur on increased volatility, cushioning the downside. What he did not realize is that many other managers had hedged similarly. When the market moved much lower faster than anyone expected, those managers fled for the sidelines to avoid early year losses. They bought back their volatility positions and sold their equity holdings. What had looked like a good hedge now created a double loss for my portfolio manager. Within the space of a couple of weeks, he faced dramatic losses in his book, a cut in the capital he was allocated to trade, and a stern message from management that further losses could result in his dismissal from the firm. To use his phrase, he was facing a “career ender”. If he were to draw down further, no one would hire him after such a blowup.

My challenge as his psychologist was that his assessment was absolutely correct. In the existing job market, his dilemma would make him close to toxic to other hedge funds. It’s one thing to help people who blow events out of proportion and then suffer from anxiety, uncertainty, and frustration. It’s quite a different matter to help people recover from truly severe setbacks. How do we recover when we lose our dreams, lose our health, lose our loved ones? These are all-too-real and life-impacting setbacks; how can we move forward in their wake?
Imagine the situation of Viktor Frankl, who, shortly after beginning his book Aerztliche Seelsorge (”The Doctor and the Soul”), decides to not emigrate to the United States so that he can be with his father. He and his family are apprehended by the Nazis and his pregnant wife is forced to abort their child. They are sent to a ghetto and then a concentration camp, where Frankl’s father, wife, and mother die. Beset with typhoid fever, Frankl avoids complete collapse by focusing on reconstructing his book on small pieces of paper. When the concentration camp is liberated, he returns to his profession as a psychiatrist and is granted a teaching appointment based upon the book he has reconstructed. In nine days time, he dictates yet another book, Man’s Search for Meaning, which has become his most famous legacy. The thesis of that book is that we can overcome life challenges by finding a purpose in life and immersing ourselves in imagining and working toward the fulfillment of that purpose. Revealingly, the original title of the book was “Nevertheless Saying ‘Yes’ to Life: A Psychologist Experiences the Concentration Camp”.

If anyone deserved to be overwhelmed with grief, trauma, loss, and depression, it was Frankl. His ability to focus on the meaningful purpose of recreating his book enabled him to nevertheless say “Yes” to life. The Heal Grief organization, which has assembled a wide range of resources to help people deal with loss, chose the hummingbird for its symbol, as the hummingbird seemingly becomes lifeless in the cold weather, only to be “resurrected” when the temperatures warm. The idea is that, in memorializing those we’ve loved and connecting to the larger meanings and influences of their lives, we can achieve a similar rebirth. The key, Frankl recognized, is finding a purpose that gives meaning to our setbacks and sufferings. Fascinating research described by Lydia Denworth finds that having a sense that life is worthwhile not only benefits our moods and health, but also is associated with greater positive life changes over a next four-year horizon. This is the value of the Option B described by authors Sheryl Sandberg and Adam Grant: when we find meaning in adversity, we build our resilience and increase our ability to move forward constructively.
Psychologist Seth Gillihan recently described lessons he has learned from a lingering debilitating illness, including accepting the situation for what it is and practicing self-compassion. Being kind to oneself, he notes, includes seeking out sources of support and reminding yourself that you’re doing the best you can. In other words, during the severe setback, you become your own support system and expand that system with the right people. Gillihan’s podcast with Dr. Jill Carnahan, who has suffered from her own chronic diseases, points out the importance of “meaning and purpose” during times of setback and sustaining a belief that something better lies ahead. Through this resilient mindset and a sense of faith and purpose, they note, we can find a “diamond” in the midst of our pain and uncertainty. This very much mirrors Frankl’s experience. He was not just sustained in the concentration camp by a positive attitude, but by an active sense of meaningful purpose. As Gillihan shared with me recently, “ I felt like I discovered my spirit at the depths of my illness and depression, and it’s what pulled me back from the brink.”

That has been my experience working with people who have experienced profound setbacks. They emerge, not just by coping, but by connecting to a deeper, more meaningful sense of self. From pain and uncertainty, they connect to a renewed sense of purpose. Sometimes this occurs through religious faith, sometimes through social support, and sometimes through the guidance of a helping professional. My portfolio manager came back from his brink, but the experience changed him forever as a risk-taker. He became more diversified in his approach to markets, spent increased time generating arrays of non-correlated ideas, and built a team to support him in these efforts. He learned that he was an effective team leader, and he affirmed that he was a creative and fertile idea generator. In a very real sense, he became a different money manager. His return from setback, like Frankl’s, like Gillihan’s, required a renewal, a rebirth, and a discovery of his spirit. We overcome major life setbacks by connecting with the essential self that is never lost.
https://www.forbes.com/sites/brettsteenbarger/2020/01/18/how-to-overcome-major-life-setbacks/#4d248a0e47ad