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By T. Mitch. Eastern Kentucky University.

Macroscopic haematuria is not uncommon cialis 2.5mg overnight delivery erectile dysfunction yoga youtube, although this should Management prompt further investigation for any other underlying Empirical antibiotic therapy is used in symptomatic pa- disease such as urinary stones or a bladder malignancy purchase 10 mg cialis erectile dysfunction treatment philippines. Both Intravenous antibiotics should be used in those who are pyelonephritis and prostatitis may be due to ascending systemically unwell or those who are vomiting 10mg cialis amex erectile dysfunction needle injection. Quinolones such present nonspecically with fever, falls, vomiting, or as ciprooxacin are useful as resistant E. Macroscopy r Intravenoustherapyisoftenwithacephalosporinwith The urine is cloudy due to the pyuria (pus cells) and or without gentamicin. Over time, recurrences can cause chronic sistance, and some centres advise a cycling regime, e. If there is any evidence of obstruction this requires rapid drainage Aetiology (see page 256). Management Mild cases may respond to oral antibiotics as for urinary Pathophysiology tract infection, but many require intravenous therapy Predisposing factors to ascending infection include suchasgentamicinandciprooxacin. Antibiotics should be tailored to the sensitivity stasis due to obstruction, dilatation or neurological and specicity, and continued for 1014 days (longer causes and reux. Clinical features Fever >38C, rigors, loin pain and tenderness with or withoutlowerurinarytractsymptoms. Denition An abscess that forms in the kidney, or in the perinephric Macroscopy/microscopy fat,astheresultofascendinginfectionorhaematogenous The kidneys appear hyperaemic, and tiny yellow-white spread. These have become less common, due to more spherical abscesses may be seen in the cortex. Aetiology Complications r As with other urinary tract infections, the most common Gram negative septicaemia causing shock is uncom- organisms are E. Necrotic renal papillae due to inammatory thrombosis of the vasa recta, can be Pathophysiology shed, causing obstruction and acute renal failure. Commonly the infection ascends via the lower urinary r Recurrent infections cause renal scarring and im- tract to cause pyelonephritis. U&Es and creatinine (assess hy- kidney into the perinephric fat, or by direct haematoge- dration and renal function). It In reux nephropathy, the papillae are damaged, and the may not be possible to differentiate it from a renal calyces become dilated and clubbed. However, hypertension Antibiotic choice is as for pyelonephritis, until culture may lead to damage to the single functioning kidney. In large abscesses (>3 cm) medi- cal therapy alone is often insufcient, and percutaneous drainage or even partial or total nephrectomy may be Clinical features required. The term should largely be replaced by reux nephropathy, the Macroscopy most common form. The kidneys are smaller than normal, with an irregular, blunted, distorted pelvicalyceal system and areas of scar- Incidence/prevalence ring 12 cm in size. Accountsforabout15%ofcasesofend-stagerenalfailure and is an important cause of hypertension in later life. Microscopy Aetiology Areas of interstitial brosis with chronic inammatory The development of chronic pyelonephritis requires cell inltration. The tubules are atrophic or dilated and there to be infections in a kidney with an underlying the glomeruli show periglomerular brosis. Intravenous pyelogram and renal ultra- and japonicum can cause proteinuria and nephrotic syn- sound may also identify damaged kidneys (but are less drome by immune complex deposition and may cause sensitive) and dilated ureters. Management Managment Patients with chronic renal failure require appropriate Praziquantel is the treatment of choice. Acute epididymo-orchitis Previously severe reux was treated with surgical re- Denition implantation of the ureters, this has now been shown to Acute primary infection of the epididymis and the testis. Denition Sex Schistosomiasis is the disease caused by the parasitic Male ukes, schistosomes. Clinical features Pathophysiology Patients present with a greatly enlarged and very tender The eggs of S. Microscopy Sex Thereisextensiveinltrationoftheseminiferoustubules M > F (4:1) and interstitium with neutrophils, initial oedema is con- siderable and there is often patchy haemorrhage. Aetiology Risk factors include: dehydration, urinary tract infec- Complications tions, disorders of calcium handling (hypercalcaemia, Infertility is an important complication. Pathophysiology Stone formation usually occurs because compounds of Management low solubility are present in the urine in high concentra- Treatment is with antibiotics, bed rest and scrotal sup- tions. In young adults, erythromycin (to cover Chlamy- such as magnesium, citrate and organic inhibitors such dia)isprobably best, whereas in older individuals or as glycoseaminoglycans and nephrocalcin. Stones commonly contain calcium oxalate (80%) but Urinary stones about half of these also contain hydroxyapatite. Incidence/prevalence The pain is characteristically in sharp, intense waves over Affects about 10% of the population at some time in abackground pain, occurring in the loin, radiating to their lives. Stones within calyces on passing urine, inability to pass urine or the sensation cannot be broken up this way. Subsequent management If the stone obstructs a single functioning kidney, To reduce the risk of recurrence, all patients should be postrenal acute renal failure results. Calcium oxalate stones may also be given to increase urine levels of citrate lookspiky,calciumphosphatestonesareoftensmooth which inhibits calcium stone formation. This should be avoided if there is carbonate to alkalinise the urine, or d-penicillamine. Strain all urine to try Despite preventative strategies recurrence rates are as to catch the stone so that it can be analysed. Some recom- Aurinary stone which lls the calyces and pelvis of a mend anti-spasmodic drugs. Ensure adequate uid in- kidney, these are usually associated with infection and take. Aetiology/pathophysiology Surgical techniques are needed if the stone does not Stag horn calculi are struvite stones (i. It may be necessary to relieve obstruction urgently, vite and calcium carbonate-apatite). Obstruction can be teus or Klebsiella causes increased amounts of ammonia, relieved by retrograde stent insertion (usually requires due to the presence of urease (which breaks down urea general anaesthetic), or percutaneous nephrostomy in- into ammonia and carbon dioxide). Characteristically the patient presents with an acutely tender swollen testis of sudden onset, there may be a Clinical features history of minor trauma or recent vigorous exercise.

Numerous fgures and tables help distil the information for revision purposes cheap 20 mg cialis erectile dysfunction exam, and there are new chapters on the medical interview and assessment discount cialis 10mg mastercard erectile dysfunction treatment los angeles. Whether you need to develop your knowledge for clinical practice cheap cialis 20mg with visa erectile dysfunction organic causes, or refresh that knowledge in the run up to examinations, Clinical Medicine Lecture Notes will help foster a systematic approach John Bradley to the clinical situation for all medical students and hospital doctors. Mark Gurnell For information on all the titles in the Lecture Notes series, please visit: www. This means that 9781444335118 our books are always published with you, the student, in mind. The Hands-on Guide for Junior Doctors, Fourth Edition Anna Donald, Mike Stein and Ciaran Hill 2011 If you would like to be one 9781444334661 of our student reviewers, go to www. Blackwells publishing programme has been merged with Wileys global Scientic, Technical and Medical business to form Wiley-Blackwell. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The seventh edition follows the format of Mark Gurnell previous editions of this book with two sections: Diana Wood Clinical Examination and Clinical Medicine. Each section has been updated to reect the increased Acknowledgements evidence upon which clinical practice is based and the more objective methods of assessment that are We would like to thank Dr Ellie Gurnell, Dr Mark now used. Lillicrap and Dr Narayanan Kandasamy for their con- It is rewarding to discover how many readers have tributions, help and advice during the preparation of found the text useful for study, for revision and for the the manuscript. P reface to th e irst ditio This book is intended primarily for the junior hospital working knowledge in a clinical situation. It should doctor in the period between qualication and the not be forgotten that some rare diseases are of great examination for Membership of the Royal Colleges importance in practice because they are treatable or of Physicians. Some for higher specialist qualications in surgery and conditions are important to examination candidates anaesthetics. The experienced phy- We have not attempted to cover the whole of sician has acquired some clinical perspective through medicine, but by cross-referencing between the two practice: we hope that this book imparts some of this sections of the book and giving information in sum- to the relatively inexperienced. A short account of psychiatry is given in the section The book as a whole is not suitable as a rst reader on neurology since many patients with mental illness for the undergraduate because it assumes much basic attendgeneralclinicsanditishopedthatreadersmaybe knowledge and considerable detailed information has warned of gaps in their knowledge of this important had to be omitted. The section on dermatology is incomplete but textbook of medicine and the information it contains should serve for quick revision of common skin must be supplemented by further reading. In are most commonly seen and where possible have the rst part we have considered the situation which a listed them in order of importance. The frequency candidate meets in the clinical part of an examination with which a disease is encountered by any individual or a physician in the clinic. This part of the book thus physician will depend upon its prevalence in the resembles a manual on techniques of physical exam- district from which his cases are drawn and also on ination, though it is more specically intended to help his known special interests. Nevertheless, rare condi- the candidate carry out an examiners request to tions are rarely seen; at least in the clinic. Wehave We should like to thank all those who helped included most common diseases but not all, and we us with producing this book and, in particular, have tried to emphasise points which are under- Sir Edward Wayne and Sir Graham Bull who have stressed in many textbooks. Accounts are given of kindly allowed us to benet from their extensive many conditions which are relatively rare. It is neces- experience both in medicine and in examining for sary for the clinician to know about these and to be on the Colleges of Physicians. Supplementary reading is essential to un- derstandtheirbasicpathology,buttheinformationwe David Rubenstein give is probably all that need be remembered by David Wayne the non-specialist reader and will provide adequate November 1975 1 T h e m edical in terview Good communication between doctor and patient forms the basis for excellent patient care and the clinical consultation lies at the heart of medical prac- Effective consultation tice. Good communication skills encompass more Effective consultations are patient-centred and ef- than the personality traits of individual doctors they cient, taking place within the time and other practical forman essentialcorecompetencefor medicalpracti- constraints that exist in everyday medical practice. In essence, good communication skills pro- Theuseofspeciccommunicationskillstogetherwith duce more effective consultations and, together with a structured approach to the medical interview can medical knowledge and physical examination skills, enhance this process. Important communication lead to better diagnostic reasoning and therapeutic skills can be considered in three categories: content, intervention. These skills are evidence-base shows that health outcomes for pa- closely interrelated so that, for example, effective tients and both patient and doctor satisfaction within use of process skills can improve the accuracy of the therapeutic relationship are enhanced by good information gathered from the patient, thus enhan- communication skills. Providing structure to the consultation is one of the There are a number of different models for most important features of effective consultation. They are generally similar and all em- that is responsive to the patient and exible for dif- phasise the importance of patient-centred inter- ferent consultations. Like all clinical skills, com- examination) munication skills can only be acquired by experien-. Before meeting a patient, the doctor should prepare by focusing him- or herself, Theinitialpartofaconsultationisessentialtoformthe tryingtoavoiddistractionsandreviewinganyavailable basis for relationship building and to set objectives for information such as previous notes or referral letters. Gathering information An accurate clinical history provides about 80% of the Explanation and planning information required to make a diagnosis. Tradition- ally, history-taking focused on questions related to the Explanationandplanningiscrucially importantto the biomedical aspects of the patients problems. Establishment of a manage- evidencesuggeststhatbetteroutcomesareobtainedby ment plan jointly between the doctor and the patient including the patients perspective of their illness and has important positive effects on patient recall, un- by taking this into account in subsequent parts of the derstanding of their condition, adherence to treat- consultation. Patient expectations should therefore include exploring the history from have changed and many wish to be more involved in boththebiomedicalandpatientperspectives,checking decision-making about investigation and treatment thattheinformationgatherediscompleteandensuring options. The goals of this part of the consultation are thatthepatientfeelsthatthedoctorislisteningtothem. Explanation and planning Gathering information Avoid jargon: use clear concise language; explain Ask the patient to tell their own story.

Zinc improves pig performance and reduces incidence and severity of diarrhoea in piglets generic cialis 2.5mg on line impotence merriam webster. The effects of the seaweed seen in the finished beef product include a more desirable colour cheap cialis 2.5 mg amex erectile dysfunction doctor in delhi, improved uniformity cialis 20 mg with mastercard neurogenic erectile dysfunction causes, decreased browning and less discoloration. They considered this research to be applicable to other species (Science Daily Magazine, 1999). Inmunologically-active compounds Some of the growth-promoting effects of the subtherapeutic use of antibiotics in feeds may result from their action against subclinical infections or competitive intestinal bacteria. For this reason, it has been suggested that the addition of these immunoactive compounds to feed may accomplish the same purpose. Application of genomics and bio-informatics to the development of new antimicrobials Recent advances in genomics have made an important contribution to drug design. The knowledge of genes and the synthesis of their proteins has allowed geneticists and chemists to use this information against bacterial resistance. However, the proteins encoded by essential genes are not the only molecular-level targets that can lead antibiotic development. Virulence factors are those responsible for overcoming the hosts immune response, allowing bacteria to colonize. The host response used to make it difficult to identify these genes, especially because the events taking place during the immune response were difficult to reproduce in the laboratory. When a tag disappears, this means that the genes they were attached to were essential for the bacterias survival, and the bacteria could not survive in the host without these genes. Researchers expected that by identifying and inhibiting these virulence factors, they might aid the bodys immune system in its fight against bacteria. In addition, this kind Risk management options 55 of research is discovering which genes confer antibiotic resistance. All the potential available targets can be evaluated almost simultaneously and target selection is determined by relationships among genomes. Some pharmaceutical companies are currently using this approach to develop new antibiotic targets. In all cases, selection entails the application of a set of selection criteria and a process of comparison. The next step is to determine whether the targets selected are essential for the micro-organisms growth under different conditions, e. In essence, determinations may be made using gene knockouts, employing genomic footprint methods or preparing temperature-sensitive mutants, the two last methods being relatively rapid. The assays may be cell-free genetic assays based on phenotype; enzymatic assays; or binding assays. Since, even after the selection and essential determination, the selection of potential targets may be a big process, so pharmaceutical companies are interested in high-throughput methods that simultaneously permit assessing a number of targets. The most important step in target evaluation is the screening for inhibitors of the gene targets. Immune modulators Recently, using a modern immunochemical technique, a new approach to fighting resistant bacteria has been proposed. Some strains of this bacterium are able to produce super antigens that can trigger an uncontrolled immune reaction, making the body attack itself. Gupta also developed a new strategy to try to stop the superantigen from binding to the cells responsible for the immune response. First, the parts of the gene for the super antigen that enable the toxin to bind to human cells were identified. Then those sequences were linked to make an artificial gene that was inserted in an E. Gupta thinks the decoy may also act against superantigens produced by other strains, such as methicillin-resistant S. This approach has the advantage that, as decoy 56 Responsible use of antibiotics in aquaculture molecule targets human cells, the bacteria cannot develop any mechanism against it. Nevertheless, the problem might be getting the decoys to the right place in the body (Gupta, 2001). Genetic switch Another advance was made by Levy at Tufts University in Boston (2001) and colleagues, working on a genetic switch in E. The switch was originally named mar because it induced multiple antibiotic resistance, but this gene not only defeats antibiotics, it controls over 60 bacterial genes, including the ones coding for virulence. If these molecules are administered to a patient with an infection, they should make the bacteria harmless. The researchers have created mutating bacteria in which Dam is either permanently inert or overproduced and they make very effective live vaccines in that way, having the advantage that the Dam vaccine protects against many strains since the mutant bacteria manufactures many different proteins that the immune system can target. They only act against specific bacteria, into which they injected their genetic material, causing the cells to produce more viruses. Phages had been used for many years to treat infectious diseases in humans, animals and plants. The technique has the disadvantage that natural viruses have evolved into replicating themselves, rather than killing cells. The antibiotic is highly effective in the treatment of infections by Gram-positive bacteria in both adults and children. Nevertheless, the overuse or misuse of these drugs may lead to the development of resistance against them, making them worthless in the therapeutical arsenal. To prevent resistance problems, the aim must be to reduce antibiotic use to therapeutic purposes only. Risk management options 57 Most of the infectious diseases reported in crustaceans refer to penaeid shrimp because they are subject to intensive aquaculture production. Viral diseases in crustaceans could be responsible for serious enzooties (or massive pandemics) in shrimp-farming countries. A number of preventive approaches are available to reduce the use of antibiotics for prophylactic purposes. Hygienic procedures It is important to note that good aquaculture management practices are essential to maintain a healthy environment for farmed finfish and crustaceans. As mentioned earlier, the most common diseases in aquaculture are infectious diseases, with various causative organisms.

Hypercalcemia rarely reaches levels that produce constipation buy 10mg cialis free shipping erectile dysfunction protocol jason, but should always be considered generic cialis 5mg with amex erectile dysfunction of diabetes, since this electrolyte disturbance can be a life-threatening disorder order cialis 10 mg with visa impotence or erectile dysfunction. Constipation in this setting is always resistant to therapy until the hypercalcemia is treated. This is due to the functional obstruction from spasm caused by the inflammation First Principles of Gastroenterology and Hepatology A. The colon more proximally continues to produce formed stool, which cannot pass easily through the inflamed rectum. Proctitis will usually be associated with excess mucus production, with or without blood in the stool, and proctosigmoidoscopy will diagnose this entity. Another cause of constipation is diabetes mellitus, which results in impaired colonic motility due to dietary factors, as well as autonomic neuropathy of the enteric nervous system, seen with long-standing diabetes mellitus. Patients with diabetes may also develop diarrhea, which again has been linked to the autonomic neuropathy. This is presumed to be secondary to reduced colonic activity due to a low fiber intake. Severe cardiopulmonary diseases of whatever cause that limit activity can also result in constipation. Neurologic disorders that cause the patient to have a reduced ability to ambulate can have constipation as a feature. Some patients with diseases of the nervous system may have impaired awareness of rectal distention to signal a need to defecate, and nerve dysfunction (both peripheral and central) may impair normal colonic propulsion. Although constipation with fecal impaction occurs they may complain of diarrhea or soiling due to overflow incontinence of stool from the fecal impaction of the rectum inhibiting the normal resting tone of the anal sphincter. Not surprisingly, many of these patients may respond to laxative therapy after the fecal impaction is removed, since this prevents the recurrence of the fecal impaction with overflow incontinence. Some patients can aggravate longstanding constipation with regular laxative abuse, and some theoretical concerns remain that this practice may indeed damage the normal innervation of the colon, rendering it atonic and nonfunctional. The physical findings are often minimal in the majority of patients with constipation, but specific secondary causes must be looked for. Signs of hypothyroidism may be present; signs of dehydration should be sought, as this may be an early indicator of hypercalcemia. Thorough cardiopulmonary and neurologic examinations are necessary to pick out associated diseases that may be treated, thereby improving the patients overall health, and thus improving bowel function and the quality of their lives. On abdominal examination, inspection for evidence of distention, hyperperistalsis or masses may point t the source of the impaired stool passage. Localized tenderness of the abdomen must be noted, along with any evidence of liver, spleen or renal enlargement. A complete digital rectal examination and proctosigmoidoscopy is required in any patient with constipation so that the presence or absence of a fecal impaction, dilation or enlargement of the rectum or the presence of proctitis can be determined. Pelvic Floor Dyssynergia The majority of patients with constipation have a form of irritable bowel Syndrome. But, there is a small subgroup of patients who may have a specific disorder in colonic and/or anorectal function that produces constipation. These patients can present major therapeutic dilemmas, and warrant further investigation in specialized coloproctology units. The Anal Canal The anal canal begins where the terminal portion of the large bowel passes through the pelvic floor muscles, and it ends at the anal verge. This is felt posteriorly and laterally as the anorectal ring on digital examination. In approximately the mid-anus there is a rolling line of demarcation called the dentate line. Above the line is columnar epithelium; below it is squamous epithelium without appendages (the anoderm). As the rectum narrows into the anal canal, the mucosa develops 6 to 14 longitudinal folds, Morgagnis columns. Blood is supplied to the anus via the inferior rectal artery, a branch of the internal pudendal artery. The superior rectal vein drains the upper part of the anal canal via the inferior mesenteric vein to the portal vein. The middle and inferior rectal veins drain the upper and lower anal canal into the systemic circulation via the internal iliac and internal pudendal veins, respectively. Lymphatic drainage above the dentate line is via the superior rectal lymphatics (accompanying the superior rectal vessels) to the inferior mesenteric nodes, and laterally along the middle and inferior rectal vessels to the internal iliac nodes. Lymphatic drainage from the anal canal below the dentate line may be in a cephalad or lateral direction, but is primarily to the inguinal nodes. Sympathetic innervation is from the first three lumbar segments via the preaortic plexus. Fibers from the preaortic plexus ultimately join the nervi erigentes to form the pelvic plexuses. Above the level of the inferior rectal nerve sensory distribution, there are only dull perceptions, mediated by parasympathetic fibers. Anorectal Spaces Around the anorectum there are a number of potential spaces filled with fat or connective tissue. The perianal space is at the anal verge, and is continuous with the intersphincteric space. The inferior boundary is the skin of the perineum, and the apex is the origin of the levator ani from the obturator fascia. Posteriorly is the gluteus maximus muscle, and anteriorly the transverse perinei muscles. On the obturator fascia is Alcocks canal, containing the internal pudendal vessels and pudendal nerve. The fossa is filled with fat, and contains the inferior rectal nerve and vessels, as well as the fourth sacral nerve. The two ischiorectal spaces communicate with one another behind the anal canal via the deep post-anal space.

Promoting the concept of employment as a health outcome Recognition of employment as an outcome of clinical care has been slowly increasing but we need to keep this on the agenda and spread the message further 5 mg cialis otc erectile dysfunction zinc supplements. Getting work on the agenda during primary care consultations might be a way of improving understanding about work and developing treatment plans which reflect this cialis 20 mg low price erectile dysfunction and pregnancy. This was raised in the Chief Medical Officers report purchase 10mg cialis fast delivery impotence treatment natural, where it was recommended that: employment status should be a routine and frequently updated part of all patients medical records. This will provide the baseline data for employment status to be an outcome of all medical specialties, including primary care (Davies, 2014). To this end, we recommend that: The Health and Social Care Information Centre, working with the Royal College of General Practitioners and other Royal Colleges, should review the existing taxonomy for the routine collection of employment data to ensure that it is usable and can be coded across all care settings. This is a change in process and the recommended activities need to be part of a comprehensive push to change the knowledge and culture of primary healthcare professionals regarding the role of employment for many people with mental health conditions. We need to continue the good work we have started and explore new ways in which we might make these changes. Further it is recommended that: An assessment is undertaken of the impact of measuring employment for those in secondary mental healthcare services in the Clinical Commissioning Group Outcome Indicator Sets. Should the outcome be positive we should consider expanding this to include people with any mental health condition, not just those in secondary care. Enhancing understanding and recognition of the symptoms of depression As highlighted in the Chief Medical Officers report, in many cases depression goes unrecognised by individuals themselves, by their clinicians or by their employers meaning many people dont receive any treatment or intervention for their condition. In order to improve employment outcomes for people with depression we need to get better at recognising symptoms of the illness so we can provide the best support. Even where depression is diagnosed, some symptoms, including cognitive symptoms such as difficulty concentrating, may be missed. Any ongoing symptoms of depression missed in treatment (particularly if access to treatment is limited) can provide an ongoing barrier to work. This need is perhaps as acute in the health environment as it is in the workplace and in employment support services. The workplace provides an important location for health and work interventions and often plays a vital role in the recognition of health conditions as well as their management. Managers need to be better equipped to support employees with mental health conditions, including in terms of preventing symptoms to escalate. It is recommended that: Mental health awareness and management training is provided to managers to enhance their understanding of employee needs. Training needs to be of a high quality, and evidence-based where possible techniques such as psycho-education may be useful. As suggested in the recent report of the Taskforce on Mental Health in Society (2015), this might be incentivised through inclusion in professional management standards and employer accreditation schemes. We would also concur with recommendations of both Mind (2014) and the Taskforce on Mental Health in Society (2015) that: Frontline staff in the Jobcentre and Work Programme providers receive training and upskilling to improve their understanding mental health conditions (including depression), helping them to better understand the needs of their clients and provide more appropriate support. It requires proactivity from the individual who may have already waited weeks or months to be contacted by the service only then to be unable to engage due to poor health, be branded as a did not attend and sent to the back of the queue. It was suggested that lessons on how to reach out to people with depression might be learnt from Assertive Outreach programmes, currently used for people with a severe and enduring mental illness, and a low-level approach might be considered. This could include health or social support staff (public or third sector) following up with people who have failed to engage with psychological therapy to identify the issues and provide support. Symptoms of depression and their effects on employment 53 It is recommended that: A form of low-level Assertive Outreach is developed and trialled to identify whether it can be used to improve engagement of patients with depression in treatment, in particular psychological therapy. For those who have had or are expected to have four weeks of sickness absence due to their depression, Fit for Work will be an option. The service will need to be monitored to see how well it is reaching people with depression and how successful it is with supporting their long-term return to work. Fit for Work assessors will also need to recognise ongoing symptoms associated with depression, which might remain a long time after remission of other symptoms and continue to cause problems at work, possibly affecting the long term sustainability of the return to work. The assessors will also need to recognise the difficulties many people with depression experience in engaging with treatment. Mitigation of the risks to the sustainability of return to work and the risks of relapse need to be addressed in return to work plans. It is recommended that: Guidance is provided to Fit for Work assessors to ensure they are aware of the likelihood of people with depression experiencing ongoing symptoms; these symptoms may be harder to spot but can have a substantial effect on return to work. In some cases there will be a need for more substantial, long term treatment of depression to ensure complete remission of symptoms. Improving access to job retention support Preventing people from losing their job in the first place is often seen as easier than finding a new job. More attention must be given to improving job retention for people with depression. External support for job retention was seen as limited especially access to specific locally-appropriate, retention-related information (e. It is recommended that: Commissioning guidance is developed that considers the distinct requirements of both return to work support and retention support for people Symptoms of depression and their effects on employment 54 with depression. A lack of specialist employment and occupational health knowledge and expertise within the health trusts was noted by the experts, in particular advocacy-related support for employees with health conditions. Various barriers were identified around accessing the Mental Health Support Service in this as in previous research. Given the effectiveness of this service in supporting retention of people with common mental health conditions, including depression, it is important that these barriers are removed to improve access for the many people who would likely benefit from it. We support the recommendations made in the recent Mind (2014) report that Access to Work should be better promoted and made more accessible for people with mental health problems. Once the hurdles to access are addressed, then we agree that Access to Work should aim to direct at least ten per cent of the budget towards this group. To this end we recommend reforms to those barriers to access identified in this research. Limited access to health services outside of working hours creates a further barrier to treatment for those in work who are seeking to remain in work. It is recommended that: Government commits itself to improving job retention for people with mental health conditions through taking steps to improve access to out of hours treatment. Improving access to evidence-based interventions There is considerable anecdotal evidence around the effectiveness of several employment support interventions for people with depression; the barriers to accessing such interventions are also apparent.