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By H. Ismael. Washington State University.

Strenuous movements of the shoulder/upper arm without simultaneous purchase effexor xr without prescription, quickly repeated movements of the shoulder/upper arm are not covered by the list order effexor xr 75 mg line. The pathological picture and the time correlation The assessment of the load must take into account the persons size and physiology generic 75 mg effexor xr mastercard. Furthermore there must be good time correlation between the onset of the disease and the neck and shoulder loading work. The first symptoms of the disease need to appear some time after the commencement of the neck and shoulder loading work. Depending on the scope of the load, some time is usually understood as several years. In such cases, from a medical point of view, there will be a time correlation between the work and the development of the disease, even if the first symptoms occur soon after the commencement of the neck and shoulder loading work. This also means that the disease must not have manifested itself as a chronic disease before the stressful work was commenced. On the other hand, a single, previous case of acute neck and shoulder pain with complete recovery does not in itself lead to the claim being turned down. It will be characteristic for chronic neck and shoulder pain to develop gradually in the course of a few years after the commencement of the stressful work and for the disease to be gradually aggravated with increasing pain in connection with continued exposure. It occasionally belongs to the pathological picture that the disease at some point in time is acutely aggravated. In such cases it is of no special significance whether such an acute aggravation occurs in connection with the work or in a different situation, as long as the aggravation actually occurs in a period of neck and shoulder loading work. If the acute aggravation for example occurs outside working hours, without it being an accident, the aggravation may still be referred to the neck and shoulder loading work. In cases where the injured person has ceased doing the neck and shoulder loading work, there must not have been any considerable aggravation after cessation of the exposure. Any substantial aggravation after cessation of the exposure would be in favour of finding that the neck and shoulder disease was not work-related. The medical specialist will among other things be asked to describe and assess the different work functions and the frequency and nature of the work movements. This description would include a detailed account of the concrete types of loads and their severity and duration in the course of the working day and seen over time. The medical specialist will also make an individual assessment of the impact of stress factors on the development of the disease in the specific examined person. Examples of pre-existing and competitive diseases/factors Muscular pain with causes other than work (for example fibromyalgia) Certain kinds of arthritis of the cervical spine and/or shoulder joint Prolapsed cervical disc Disease/symptoms caused by degeneration of tissue and bones Effects of whiplash injury Previous neck and shoulder pain (onset before commencement of the stressful work) Arthritic degeneration Arthritic degeneration shown in an x-ray of the cervical spine, the acromio-clavicular joint or the shoulder joint does not in itself lead to the claim being turned down. What matters is the degree to which this arthritic degeneration gives or will give symptoms of significance for the assessment of the reported disease. Chronic neck and shoulder pain and degeneration of the rotator cuff tendons of the shoulder joint If it is merely a case of degeneration of the rotator tendons of the shoulder joint, this disease cannot be recognised on the basis of the item on the list regarding chronic neck and shoulder pain. Managing claims without applying the list Only chronic neck and shoulder pain (cervicobrachial syndrome) is covered by item B. There furthermore need to have been exposures meeting the recognition requirements of the list. Other unlisted diseases or exposures will in special cases qualify for recognition after submission to the Occupational Diseases Committee. By way of example, an exposure that may qualify for recognition after submission to the Committee is a very strenuous load on the neck and shoulder musculature without simultaneous, quickly repeated work movements within the meaning of the list. Another example might be extremely quickly repeated movements of shoulders/upper arms, perhaps in combination with other particular loads on the neck and shoulder musculature, for a period of less than 6 years. Examples of decisions based on the list 211 Example 1: Recognition of chronic neck and shoulder pain (industrial seamstress for 7 years) The injured person worked full time for well over 7 years as an industrial seamstress, sewing work clothes at an overlock sewing machine. The work involved quickly repeated movements of shoulders/upper arms, about 20 times per minute. During her work, in step with the sewing process, she led her arms and shoulders forward. The neck and shoulder girdle was fixated in largely the same position most of the time, only briefly interrupted when she had to pick up a new unit. In the last year she developed chronic pain of the neck and shoulder region and a medical specialist diagnosed her with chronic neck and shoulder pain with considerable tenderness (severity 3-4) in five of the areas of the neck and shoulder musculature. The seamstress was diagnosed with chronic neck and shoulder pain, after having performed quickly repeated movements of shoulders/upper arms with a simultaneous, long-lasting static load on the neck and shoulder girdle, after sewing full time and for a number of years. As there were quickly repeated movements of the shoulders/upper arms more than 15 times a minute in combination with a long- lasting, static load on neck and shoulder girdle, it is possible to reduce the requirement to the duration of the load from the normal 8-10 years to 7 years in this case. Furthermore there is good time correlation between the neck and shoulder loading work and the onset of the disease. Example 2: Recognition of chronic neck and shoulder pain (slaughterhouse worker for 6 years) A 48-year-old man worked full time as a slaughterhouse worker for 6 years. His work mainly consisted in deboning and cutting up large meat units with a saw or knife. Part of the cutting work he performed in a standing posture, cutting suspended meat units with his arms lifted, whereas he performed other cutting and deboning tasks in a standing posture at a conveyor belt. The work was generally charac- terised by movements of the right shoulder/upper arm, 10-15 times per minute, and simultaneous, substantial exertion of the right shoulder. Furthermore, half of the working time the work was characterised by prolonged bending of the neck when he was cutting and deboning, standing at a conveyor belt. Towards the end of the period he developed chronic neck and shoulder pain, both on the right and the left side of the neck and shoulder girdle, with tenderness (degrees 3-4) in most of the 12 muscle areas of the neck and shoulder region. Most of the time his work was characterised by repeated movements of mainly his right shoulder/upper arm, 10-15 times per minute, with simultaneous, heavy exertion of his right shoulder and prolonged bending of the neck. As the work involved repeated shoulder movements in combination with heavy exertion of the shoulder and long-lasting bending of the neck, the requirement to the duration of the load can be reduced from the normal 8-10 years. The requirement to the number of shoulder movements per minute can likewise be reduced from more than 15 movements per minute to, in this instance, 10-15 movements per minute. This is because the work involved heavy exertion of the right shoulder and bending of the neck.

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The thromboembolus will travel long with the venous return & reach the right side of the heart effexor xr 150mg online. Depending on the size of the embolus and on the state of pulumonary circulation cheap effexor xr online amex, the pulmonary embolism can have the following effects: 1 order effexor xr with visa. If the thrombus is large, it may block the outflow tract of the right ventricle or the bifurcation of the main pulumonary trunk (saddle embolus) or both of its branches, causing sudden death by circulatory arrest. Sudden death, right side heart failure (cor pulmonale), or cardiovascular collapse occurs when 60% or more of the pulumonary circulation is obstructed with emboli. If the embolus is very small (as in 60-80% of the cases), the pulmonary emboli will be clinically silent. Embolic obstruction of medium sized arteries manifests as pulmonary haemorrhage but usually does not cause infarction because of dual blood inflow to the area from the bronchial circulation. In turn, two thirds of intracardiac mural thrombi are associated with left ventricular wall infarcts and another quarter with dilated left atria secondary to rheumatic valvular heart disease. The major sites for arteriolar embolization are the lower extremities (75%) & the brain (10%), with the rest lodging in the intestines, kidney, & spleen. The emboli may obstruct the arterial blood flow to the tissue distal to the site of the obstruction. The infarctions, in turn, will lead to different clinical features which vary according to the organ involved. Fat Embolism Fat embolism usually follows fracture of bones and other type of tissue injury. Although traumatic fat embolisms occur usually it is as symptomatic in most cases and fat is removed. But in some severe injuries the fat emboli may cause occlusion of pulmonary or cerebral microvasculature and fat embolism syndrome may result. Fat embolism syndrome typically begins 1 to 3 days after injury during which the raised tissue pressure caused by swelling of damaged tissue forces fat into marrow sinsosoid & veins. Air embolism Gas bubbles within the circulation can obstruct vascular flow and cause distal ischemic injury almost as readily as thrombotic masses. Air may enter the circulation during: Obstetric procedures Chest wall injury In deep see divers & under water construction workers. Generally, in excesses of 100cc is required to have a clinical effect and 300cc or more may be fatal. The bubbles act like physical obstructions and may coalesce to form a frothy mass sufficiently large to occlude major vessels. Amniotic fluid embolism It is a grave but un common, unpredictable complication of labour which may complicate vaginal delivery, caesarean delivery and abortions. The amniotic fluid containing fetal material enters via the placental bed & the ruptured uterine veins. The onset is characterized by sudden severe dyspnea, cyanosis, hypotensive shock followed by seizure & coma of the labouring mother. As discussed in this & the previous subtopics, the potential consequence of thromboembolic events is ischemic necrosis of distal tissue, known as infarction. Infarction Definition: An infract is an area of ischemic necrosis caused by occlusion of either the arterial supply or venous drainage in a particular tissue. Other mechanisms include [almost all of them are arterial in origin]: Local vasospasm Expansion of atheroma due to hemorrage in to athermotous plaque. The effect of such a dual blood supply is that if there is obsrtuction of one of the arterial supplies, the other one may offset the rapid occurrence of infarction in these organs unlike the renal & splenic circulations which have end arterial supply. Infarction caused by venous thrombosis is more likely to occur in organs with single venous outflow channels, such as testis &ovary. B: Rate of development occlusion Slowly developing occlusions are less likely to cause infraction since they provide time for the development of collaterals. Neurons undergo irreversible damage when deprived of their blood supply for only 3 to 4 minutes. D: Oxygen content of blood Partial obstruction of the flow of blood in an anaemic or cyanotic patient may lead to tissue infarction. Types of infarcts Infarcts are classified depening on: A) the basis of their colour (reflecting the amount of haemorrhage) into: 1. Anemic (White) infarcts B) the presence or absence of microbial infection into: 1. Red infarcts occur in: a) Venous occlusions as in ovarian torsion b) Loose tissues such as the lung which allow blood to collect in infarct zone. White infarcts occur in: a) Arterial occlusion in organs with a single arterial blood supply. Morphology of infarcts Gross: All infarcts are wedge-shaped with the occluded vessel at the apex and the periphery of the organ forming the base of the wedge. Following inflammation, some of the infarcts may show recovery, however, most are ultimately replaced with scars except in the brain. Microscopy: The dominant histologic feature of infarction is ischemic coagulative necrosis. The brain is an exception to this generalization, where liquifactive necrosis is common. Myocardial infarction Usually results from occlusive thrombosis supervening on ulcerating atheroma of a major coronary artery. Cerebral infarcts May appear as pale or hemorrhagic A fatal increase in intracranial pressure may occur due to swelling of large cerebral infarction, as recent infarcts are raised above the surface since hypoxic cells lack the ability to maintain ionic gradients & they absorb water & swell. Splenic infarcts - Conical & sub capsular - Initially dark red later turned to be pale. Tissue thromboplastin substance may be derived from a variety of sources such as: A: Massive trauma, severe burns & extensive surgery. B: Obstetric conditions in which thromboplastin derived from the placenta, dead retained fetus, or amniotic fluid may enter the circulation. Endothelial injury: Widespread endothelial injury may result from: - Deposition of antigen-antibody complexes as it occurs in systemic lupus erythematosus - Extreme temperature eg. This may lead to ischemia of the more severely affected or more vulnerable organs and hemolytic anemia resulting from fragmentation of led cells as they squeeze through the narrowed microvasculature (Microangiopathic haemolytic anaemia). Second, a hemorrhagic diathesis may dominate the clinical picture because of consumption of the coagulation factors and increased fibrinolysis. The onset may be fulminant when caused by endotoxic shock or amniotic fluid embolism or it may be chronic in the case of carcinomatosis or retention of dead fetus. Shock Definition: Shock is a state in which there is failure of the circulatory system to maintain adequate cellular perfusion resulting in widespread reduction in delivery of oxygen & other nutrients to tissues.

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