Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Osler-Weber-Rendu Disease


Related Terms

  • Familial Hemorrhagic Telangiectasia
  • Hereditary Hemorrhagic Telangiectasia
  • Osler-Rendu Disease
  • Osler-Weber-Rendu Syndrome

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Dermatologist
  • Gastroenterologist
  • Hematologist
  • Internal Medicine Physician
  • Neurologist
  • Pulmonologist

Comorbid Conditions

  • Arteriosclerosis
  • Clotting disorders
  • Disorders requiring anticoagulation therapy

Factors Influencing Duration

Factors influencing duration include the frequency and severity of blood loss, the degree of internal lesions and bleeding, the effect on the individual's outward appearance, and the development of complications.

Medical Codes

ICD-9-CM:
448.0 - Hereditary Hemorrhagic Telangiectasia; Rendu-Osler-Weber Disease

Overview

This genetic (chromosomal) autosomal dominant disorder impedes the development of a small percentage of tiny capillaries that route arterial blood into veins for return to the heart. Instead, the affected arteries connect directly to the veins. Because of the difference in arterial and venous blood pressure, ruptures tend to occur where the arteries and veins directly join, resulting in bleeding into the skin, mucous membranes, or internal organs. Symptoms of the disorder often first appear in childhood as recurrent nosebleeds due to ruptures in the mucous membranes that result in bleeding. In the nineteenth century, the condition usually was mistaken for a blood clotting disorder similar to hemophilia.

Incidence and Prevalence: The annual incidence of OWRD is 1 to 2 cases per 100,000 population (Wolfe).

Worldwide, the prevalence of OWRD is 10 to 20 cases per 100,000 population (Wolfe) with significant variance among regions. In Japan and Europe, incidence is 1 case per 5,000 to 8,000 population (Soriano). Prevalence of OWRD in the Dutch Antilles is 1 case per 200 population; in France, 1 case per 8,345 population; and in northern England, 1 case per 39,216 population (Soriano).

Source: Medical Disability Advisor



Causation and Known Risk Factors

OWRD is most common in Caucasians but has been observed in individuals of African, Asian, and Arabic descent. Males and females are equally affected. The syndrome most often presents between ages 30 and 40 but may be clinically silent (Wolfe).

Source: Medical Disability Advisor



Diagnosis

History: The individual may report frequent nosebleeds (90% of cases), spitting up of blood, or black or bloody stools, a sign of gastrointestinal bleeding (10% to 40% of cases) (Wolfe). Recurrent or spontaneous bleeding or hemorrhaging precipitated by minor trauma also may be reported. By age 30, up to 50% of individuals will notice skin (cutaneous) telangiectasia characteristic of the disorder (Soriano).

Physical exam: Osler-Weber-Rendu disease (OWRD), also called hereditary hemorrhagic telangiectasia (HHT), is an inherited vascular disorder. This disease involves widespread abnormalities throughout the cardiovascular system that cause permanently dilated small blood vessels that manifest as focal red lesions of the skin and mucous membranes (telangiectasia); defects that affect both the arteries and veins (arteriovenous malformations); and bulges that are formed by dilated artery or vein walls (aneurysms). OWRD usually is recognized by a triad of characteristics that include telangiectasia, recurrent nosebleeds (epistaxis), and a family history of the disorder (Wolfe).
The exam reveals small (less than 5 mm in diameter) red to violet telangiectasia most often visible on the face, lips, mouth, nose, ears, tongue, hands, feet, chest, and under the nails (Soriano); this finding is present in 58% to 79% of cases (Wolfe). These lesions bleed easily, may be flat or raised, and turn white (blanch) on pressure. The skin may appear yellowed (jaundiced), and the extremities may reveal a thickening of the flesh beneath the fingernails and toenails with downward curving nails (clubbing).

Tests: Diagnostic tests include a complete blood count (CBC) for evidence of anemia, platelet count, and arterial blood gas (ABG) determinations. Blood clotting tests (prothrombin time [PT], partial prothrombin time [PPT]) may be done. Stool may be tested for evidence of occult blood. As symptoms warrant, the stomach and bowel may be examined using fiberoptic instruments (endoscopy, colonoscopy, sigmoidoscopy), or radiologic scans (upper and lower gastrointestinal [GI] series) may be performed. These typically are used to detect internal lesions and pinpoint GI tract blood loss.

Brain and lung screenings are important because complications in these areas can cause serious damage without any warning. Individuals with OWRD will be screened upon diagnosis for vascular malformations in the brain using magnetic resonance imaging (MRI). In addition, individuals will be screened for circulatory abnormalities in the lung (pulmonary A-V fistula); this will include at least one heart/lung screening using ultrasound (echocardiography), chest x-ray, or computed tomography (CT). An enlarged liver may be revealed.

Source: Medical Disability Advisor



Treatment

Aspirin and other drugs that reduce the ability of blood to clot are contraindicated. Visible and/or accessible lesions are treated with local applications of pressure and topical vasoconstricting agents (hemostatics) to stop bleeding. They also may be treated with laser coagulation therapy. Individuals should be protected from trauma and unnecessary bleeding and instructed in how to treat minor bleeding episodes and how to recognize major episodes that require immediate medical treatment.

Using a home humidifier and lubricating the lining of the nose may reduce the frequency of nosebleeds. If this is not effective, laser coagulation therapy generally gives good results with less risk of damage to the lining of the nose than electric or chemical cauterization. For intractable cases, surgical replacement of the lining of the nose with a skin graft (septal dermoplasty) may be considered. Other surgical treatments include cryosurgery, arterial ligation, irradiation, endovascular embolization, and subcutaneous resection.

Gastrointestinal bleeding generally is not treated unless it is copious enough to cause iron deficiency in the blood (anemia). In such cases, oral or injectable iron or folate supplements are prescribed. If iron supplementation does not correct anemia, it may be necessary to deal with the GI bleeding directly using endoscopic laser therapy. If GI bleeding is severe, part of the intestinal tract may need to be surgically removed (segmental bowel resection). Hormone therapy with oral estrogen-progesterone combination medications also has been helpful in certain individuals, but because of the risk of thrombotic events should be avoided in individuals with lung involvement (Wolfe).

Vascular abnormalities detected in the lungs or brain should be treated before they cause problems. Depending upon the size, structure, and location of the vessel in question, the vessel may need to be blocked by inserting a catheter through the groin (embolization), surgically tied off (ligation), surgically removed (excised), or destroyed using targeted radiation (stereotactic radiosurgery).

Periodic blood transfusions may be necessary to restore blood volume in cases of acute hemorrhage; these individuals should receive hepatitis B vaccine as a precaution. Individuals with pulmonary arteriovenous malformations are instructed to use prophylactic antibiotics before dental and surgical procedures (Wolfe).

Source: Medical Disability Advisor



Prognosis

OWRD is a lifelong condition. The disease generally is manageable with proper medical treatment and regular follow-up. When well managed, individuals should experience only periodic episodes of disability related to specific bleeding episodes or the development of complications. Longevity is not necessarily reduced nor is quality of life necessarily impaired. Approximately 30% to 60% of individuals will have liver involvement; 25% to 30% will experience gastrointestinal bleeding, and 10% to 20% will have central nervous system involvement (Soriano). About 10% of individuals with OWRD will eventually die of complications related to the disease (Schwartz).

Source: Medical Disability Advisor



Complications

Complications associated with OWRD include arteriovenous malformations, anemia from gastrointestinal bleeding, lung hemorrhage, hemorrhage in the brain (hemorrhagic stroke), cerebral abscess or cerebral embolism, heart failure, esophageal varices, liver cirrhosis, and enlarged liver (hepatomegaly). Repeated blood transfusions become necessary in 10% to 30% of cases (Wolfe). Bluish skin coloring (cyanosis), shortness of breath upon exertion, and clubbed fingers result from oxygen deficiency due to vascular abnormalities in the lungs.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

In mild cases, no work accommodations may be necessary depending on job responsibilities. If the individual has frequent or severe nosebleeds or subcutaneous bleeding, assignment to sedentary duties where there is little chance of trauma may be appropriate. Work accommodations also may include frequent rest periods to relieve extreme fatigue related to iron-deficiency anemia. If the individual experiences this complication and works in an occupation generally associated with high stress and long hours, a part-time schedule or other accommodations may be required in order to allow the individual to continue to work.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have the characteristic triad of symptoms (red lesions on the skin or mucous membranes, recurrent nosebleeds, and a family history of the disorder)?
  • Has individual had any neurological complications? Pulmonary complications? Gastrointestinal complications?
  • Was telangiectasia present on physical exam?
  • Has individual had the appropriate blood tests?
  • Has individual's stool been tested for occult blood?
  • Was GI tract appropriately examined?
  • Has individual been screened for brain and lung complications?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Does individual avoid the use of aspirin and other drugs that impair the ability of the blood to clot?
  • Is it time to consider more aggressive treatment?
  • Has individual been instructed on ways to prevent some symptoms (avoiding trauma, using a humidifier, lubricating nostrils)?
  • Has individual been instructed how to treat minor bleeding episodes and how to recognize major episodes that require immediate medical treatment?
  • Does individual require laser coagulation therapy? Septal dermoplasty?
  • Is individual experiencing anemia from gastrointestinal bleeding?
  • Is individual receiving iron and/or folate supplements?
  • Is gastrointestinal bleeding under control, or are more aggressive treatments such as endoscopic laser required? Is segmental bowel resection needed?
  • Have the vascular abnormalities in the brain or lungs been treated?
  • Has individual needed periodic blood transfusions to restore blood volume?
  • Has individual received all hepatitis B vaccinations?
  • Is individual with pulmonary complications receiving antibiotics before dental or surgical care?

Regarding prognosis:

  • Is individual's employer able to accommodate any needed restrictions?
  • Does individual have any conditions such as clotting disorders or disorders requiring anticoagulation therapy?
  • Has individual had any complications? To what extent?
  • Have complications been successfully treated? If not, should individual see a specialist?

Source: Medical Disability Advisor



References

Cited

Schwartz, R. A. "Osler-Weber-Rendu Syndrome." eMedicine. Eds. Mark A. Crowe, et al. 6 May. 2009. Medscape. 8 Oct. 2009 <http://emedicine.medscape.com/article/1086114-overview>.

Soriano, Perry A., James Petros, and James F. McKinsey. "Osler-Weber-Rendu Disease." eMedicine. Eds. William H. Pearce, et al. 15 Dec. 2008. Medscape. 8 Oct. 2009 <http://emedicine.medscape.com/article/461689-overview>.

Wolfe, Lawrence C., Arun Panigrahi, and Norman A. Silver. "Osler-Weber-Rendu Syndrome." eMedicine. Eds. Sharada A. Sarnaik, et al. 5 Dec. 2008. Medscape. 8 Oct. 2009 <http://emedicine.medscape.com/article/957067-overview>.

Source: Medical Disability Advisor






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