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Radiation there was evidence of pleural or chest wall involvement damage is a progressive disorder with disability and long at the time of surgery, it is likely that the pain is due to survival. Social and Physical Disability Signs and Labora to ry Findings Moderate impairment of social and occupational activ There is usually tenderness, sensory loss, and absence of ity, with depression related to chronic illness. Auscultation of the Pathology chest may reveal decreased breath sounds due to under Local skin, subcutaneous, skeletal, or visceral metastatic lying lung consolidation or a malignant pleural effusion. Page 144 Usual Course most frequently associated with sharp, spontaneous If the pain is due to traumatic neuromata, it usually de pains radiating to the chest, axilla, or neck. The pain clines in months to years and can be relieved by antide may be mild, moderate, or intense. If the pain is due to tumor recurrence, some relief may be ob Associated Symp to ms tained by an intercostal nerve block or radiation therapy. The patients usually do not to lerate contact with clothing or the water of the shower. Immobility of the upper extremity because of exacerba tion of the pain may result in a frozen shoulder. Aggres Signs and Labora to ry Findings sive physiotherapy is necessary to prevent this While the area is anesthetic or hypoesthetic, most pa complication. For benign disease, the pathology is that of neuroma Most patients will continue to demonstrate slow healing formation. If there is an underlying malignancy, there is at the site of the median sterno to my. An active bone tumor infiltration of the intercostal neurovascular bun scan may be found up to 4 years after surgery due to dle. Summary of Essential Features and Diagnostic Criteria Usual Course Persistent or recurrent pain in the distribution of the tho Without treatment the pain may decrease in intensity raco to my scar in patients with lung cancer is commonly during the first year post surgery, may remain the same, associated with tumor recurrence. Thoracic sympathetic gan the diagnostic procedure of choice to demonstrate this glia blocks may significantly reduce pain, allodynia, and recurrence. Differential Diagnosis Complications Epidural disease and tumor in the perivertebral region Pain can be compounded by emotional stress and suspi can also produce intercostal pain if there is recurrent cion of recurrence of heart disease. Social and Physical Disability Code Depending on the degree of discomfort, impairment 303. Patients System may benefit from reassurance that this pain does not Peripheral nervous system. Main Features Differential Diagnosis Burning pain across a well-circumscribed area defined Ischemic heart pain, cos to chondritis, hyperesthesia from by the sternum medially, the intercostal junction at T2 or the scar. T3 superiorly, the intercostal junction at T5 or T6 inferi orly, and approximately the nipple line laterally. Site Most frequent in precordium; may be associated with Either symmetrical, more often in the posterior thoracic tachycardia and fear or conviction of heart disease being region, or precordial. Main Features Tension pain is rare in the posterior thoracic region Code compared with tension headache (perhaps one-tenth or 31 X. Precordial pain is more common, often associated with tachycardia or a fear of heart disease.

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In a 12-week, double-blind, flexible-dose study (427), 191 In a 12-week, randomized, fixed-dose trial (82), sub subjects were randomly assigned to receive placebo or jects were assigned to sertraline 50 mg/day (n=80), 100 paroxetine, with the dose increasing from 20 mg/day to mg/day (n=81), 200 mg/day (n=80), or placebo (n=84). Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder 47 f. Venlafaxine even at the higher end of short trial length, low venlafaxine dose, and lack of stan the dosing range was well to lerated. Only a small percentage clinical evaluations) for at least 1 year with venlafaxine of patients (5%) dropped out because of adverse effects. However, the small sample size, the lack limited by differences in the number of failed trials in pa of a placebo control group, and a less stringent response tients included in a given study, by absence of information criterion are methodological limitations in this second about the number of failed adequate trials, by differences study. Other Antidepressants week, random-assignment, open-label comparison of phenelzine 75 mg/day (n=12 completers) and clomip a. Results of Second-Generation Antipsychotic Augmentation in Treatment-Resistant Obsessive-Compulsive Disorder (Double-Blind, Placebo-Controlled Trials) Mean Final Active Drug: Percentage of a Final Dose Dose Range Responders /Total Responders, Medication (mg/day) (mg/day) (N) Drug/Placebo b Carey et al. The authors con 235 mg/day) and 6 patients who completed the placebo cluded that clozapine is ineffective as monotherapy in pa trial found no evidence of efficacy (450). Risperidone the long-term effects of antipsychotic augmentation Three double-blind, placebo-controlled studies, albeit of have not been systematically studied. All 8 receive 8 weeks of adjunctive risperidone (n=10) or pla subjects with co-occurring tics responded to haloperidol, cebo (n=6). Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder 53 In a single-blind placebo-controlled study (462), 27 1. An 8-week, double-blind, pla a 4-week, double-blind, placebo-controlled, crossover cebo-controlled trial examined pindolol augmentation of trial (n=13), however, buspirone was no better than pla fluvoxamine in 15 patients (180). In addition, an 8-week open trial of buspirone the two treatment groups were noted either in symp to m at a dose of 60 mg/day for the last 5 weeks of the trial re atic response or in the latency of response to fluvoxamine. No group differences pirone did not differ from placebo, although 29% (4/14) were found in pulse rate or blood pressure. A 6-week, double-blind, placebo-controlled pindolol and a sero to nergic antidepressant, but only after trial of buspirone 60 mg/day as an augmentation of flu tryp to phan was added (465). A data weakly suggest that inosi to l may benefit a minority of small pilot study provides slight additional support (480). In a double-blind, crossover study, inosi to l (18 gm/day) and placebo were administered for 6 weeks in each condi g.

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With syncope due to other cardiovascular causes, a person should not perform Category 1 Safety Critical Work for at least 3 months, after which time their ongoing ftness for duty should be assessed. In cases where it is not possible to be certain that an episode of loss of consciousness is due to syncope or some other cause, refer to Section 18. Medical criteria for Safety Critical Workers There are 2 aspects of the medical standards regarding cardiac conditions and Safety Critical Work. One is the non working period (Temporarily Unft for Duty) following a cardiac event or intervention, which is mainly relevant to Category 1 Safety Critical Work, and the other is the criteria regarding long-term ftness for duty in relation to a range of cardiovascular conditions that may be relevant to Categories 1 and 2 Safety Critical Work. The person should be classifed as Temporarily Unft for Duty for the appropriate period as shown in Table 5. The variation in non-working periods refects the varying effects of these conditions, including the time needed for recovery from discomfort of an intervention to resume necessary musculoskeletal work, as well the time needed to assess stabilisation of the condition or a device. These exclusion periods are minimum advisory periods only and are based on expert opinion. The classifcation of Fit for Duty Subject to Review should be considered once the condition has stabilised and safe working capacity can be assessed, as outlined in this section. If there is uncertainty, the advice of an occupational physician with railway industry experience should be sought regarding a risk assessment of the job. Criteria for long-term ftness for duty Standards for chronic disorders are made with the presumption that the disorder is stable and well controlled. If this is not the case, a specialist consultation should be conducted and the person may need to be classifed Temporarily Unft for Duty while such opinion is being sought. A classifcation of Fit for Duty Subject to Review may be recommended after initial assessment by an appropriate specialist. Applicability to Category 1 and/or Category 2 workers varies depending on the condition and is shown in the table. In general, the review interval should not exceed 12 months for Category 1 workers with diagnosed cardiac disease (as distinct from raised risk fac to rs). Where a condition has been effectively treated and there is minimal risk of recurrence, the worker may be classifed as Fit for Duty (with no requirements for more frequent review) on the advice of a specialist. While awaiting results, classify as Fit for Duty Subject to Review or Temporarily Unft for Duty depending on overall risk assessment. While awaiting investigation, classify as Fit for Duty Subject to Review or Temporarily Unft for Duty depending on overall risk assessment.

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