John Teerlink, MD
 https://profiles.ucsf.edu/john.teerlink Corns virus united states department of justice buy flagyl 400 mg with visa, calthe initial evaluation should include a history antibiotics gram positive cocci buy flagyl 200 mg with mastercard, physical exam antibiotics for severe uti discount 400mg flagyl amex, luses virus dmmd buy 250mg flagyl with amex, and any bony deformities deserve a thorough descriplaboratory evaluation, and referrals for specialized evaluation. Neurologic examination includes vibratory sensation, the evaluation should classify the patient into diabetes type, light touch, and proprioception of the feet; light touch can best identify any current diabetes complications, and help develop be assessed with the use of a monofilament. Given the increased An initial referral for dilated eye exam is indicated for all risk of heart disease, a high priority is to identify other cardiopatients with type 2 diabetes shortly after diagnosis and for vascular risk factors, especially hypertension, dyslipidemia, patients with type 1 diabetes within 5 years of diagnosis and smoking. Symptoms to ask about include visual problems, (Strength of Recommendation Taxonomy B). Podiatry periodontal irritations, skin rashes, fatigue, sexual dysfuncreferral may also be indicated depending on the findings on tion, and paresthesias (4). Diabetes education and medical nutrition refershould also ask about diabetes and premature cardiovascular rals are also indicated to help support self-management. If there is a family history of diabetes, inquire about any complications of diabetes in family members. For women Diagnostic testing who have had children, a history of gestational diabetes or havTable 13. The best ing a baby weighing more than 9 lb are important evidence of test to obtain depends on the clinical presentation. In the absence of significant hyperglycemia, accurate enough at this time to be used for diagnosis (3). All three tests include ranges that place patients at Diabetes Symptomatic and a random plasma increased risk for diabetes (3). Obtain hemoglobin A1C to examine blood glucose con2-hour (75g) glucose tolerance test trol over the previous 3 months. Screen all type 2 diabetics with a microalbumin/creatinine test to determine future risk of *Based on the 2010 American Diabetes Association recommendations (3). Conveying the Diagnosis Comprehensive management of diabetes must deal with both the metabolic problems and the increased risk of cardiovascuthe first task of the clinician who has made a diagnosis of dialar disease. It requires ongoing attention to cardiovascular risk betes is to convey this news to the patient. Patients with a factors, education, and support in self-management of the disrecent diagnosis of diabetes need additional time and attenease, and a focus on metabolic goals of therapy. Diabetes is a condition that requires patient participation goals, patients and their physicians need to combine behavioral in its management. Patients face the prospect of a lifelong strategies with pharmacologic interventions. Within the table and in the subsequent discussion, differinvolvement in self-management of diabetes at an early stage. In about diabetes, and this can be an opportunity to dispel those contrast, tight blood glucose control reduced the same endpoints myths. In another randomized trial, the number failure from diabetes, this can open a conversation. Although all of these At this point you are ready to introduce the basic concepts of drug classes have proven efficacy against macrovascular commanaging diabetes. See Chapter 11 for further sis to making a solid commitment to longstanding behavior information on treatment of hypertension. Closure of the visit acknowledges that it takes time to One of the most important things that a smoker with diabetes learn to live well with diabetes. A key message the patient can do to improve his or her health is to quit smoking (16). It is a good idea to provide the patient with to quit varies between 8 and 13 depending on the length of the some reading materials that will reinforce these initial concounseling and the number of counseling sessions (16). Similarly, in a hypothetical cohort that is 86% women, one would need to treat 56 women for 3 years to Aspirin Prophylaxis prevent one stroke. Evidence-based recmetabolic syndrome or, more recently, the construct of global ommendations need to take both of these factors into account. Now with generic statins available at where benefits of aspirin outweigh the risks. In terms of cardiovascular mortality, there was 1 death lifestyle modification in most patients. In patients unable to take a statin, consider reduction in all cause mortality in the aspirin group, but this did fibrates over other antihyperlipidemics as they have been not achieve statistical significance (21). Although historically there have been concerns of worseneffect in early months of the diet, but both weight and blood ing glucose levels in people treated with niacin to improve sugar levels are similar at 1 year (39). Overall, the level of evidence for Other general dietary recommendations include increasing combining statins with other agents is not as strong as high-dose fiber intake, whole grains, fruits and vegetables, and reducing statins alone, and combination therapy increases the risk of liver saturated fats and trans fats. Some patients may benefit from a abnormalities, myalgias, and rhabdomyolysis (33). Long-term successful management of blood glucose to a goal of Exercise is an essential component of management of diabetes. This has been shown for both type 1 (34) and type 2 or 20 minutes per day of moderate intensity aerobic physical (35) diabetes. The relationship between management of hyperactivity, and in the absence of comorbid contraindications, glycemia and risk of macrovascular complications has historistrength training 2 days per week. Another study found that exercise lowered abdomDiabetes Care and Complications Trial demonstrated that sucinal visceral fat, increased insulin sensitivity, and improved cessful management of blood glucose to a goal A1C of 7. For women of reproductive age, conFor patients who do not reach their A1C goal with behavioral traception until excellent glycemic control has been achieved is management, drug therapy is recommended. The initial behavioral changes that are required with diabetes the United Kingdom Preventive Diabetes Study include dietary changes and physical activity. The major findings of sugar levels and remain the initial focus in a patient with diathis 10-year study can be summarized as follows: betes. Helping the patient identify the and/or additional agents to reach glycemic goals. Metformin is elimiMetformin nated by the kidneys; therefore, it is to be avoided when the As discussed previously, metformin is recommended as initial serum creatinine is 1. To minimize these processes in patients with diabetes, including blood lipids, effects, start at 500 mg once per day (with the evening meal) blood pressure, and clotting activity. The maximum dose is 2,550 mg daily given in divided Thiazolidinediones doses with meals. These drugs lower A1C by glycemia can occur with strenuous exercise without caloric an average of 1. They can be used alone or in combination Metformin inhibits lactate metabolism, and the greatest therapy with metformin, sulfonylureas, or insulin. Risk factors include age they are contraindicated in patients with active liver disease or older than 80 years, concurrent diuretic therapy, recent radiliver enzymes greater than 2. To minimize the aminotransferase) should be monitored before beginning these risk of lactic acidosis, metformin should not be used in peodrugs and every 2 months during the first year of therapy. Also, the drug should be discondiate testing of liver function, and the development of jauntinued before and for 48 hours after radiographic studies dice should prompt immediate drug discontinuation while with intravenous contrast that may transiently affect renal further evaluation is pending. Therefore, preexisting New York Heart Association monary disease, or active alcoholism. Subsequent studies have neither confirmed nor the monthly cost of generic metformin is approximately refuted these findings for rosiglitazone. They can occasionally induce ovulainsulin secretion and increasing tissue sensitivity to insulin. However bacteria biofuel flagyl 500mg amex, it was clear that their son had the most serious form antibiotic bloating 200 mg flagyl otc, which occurs in only a small proportion of babies with epidermolysis bullosa bacterial spores purchase flagyl 500mg free shipping. It was obvious that Freddie was suffering and he was given morphine52 for pain relief antibiotic resistance report cheap flagyl 500mg fast delivery. The dose was increased to control the pain, until the point came that his breathing started to be affected. The parents were still very concerned that their child might be in severe pain and asked the medical staff to continue to increase the dose of morphine, which was done. They did not want him to be mechanically ventilated if he stopped breathing, and the clinicians agreed to this request. Surfactant is needed to help keep the air sacs of the lungs open but babies who are born early do not produce enough; they rapidly develop breathing difficulties and need supplemental oxygen. Organisations with websites such as this can provide information on particular conditions, enable people and families who are affected to establish contact, raise funds for research and raise awareness of the condition. Other painkillers used for severe pain, including diamorphine, pethidine and fentanyl, would have similar effects on breathing. This condition is very distressing to witness, not just for the parents but also for clinical staff. It is crucially important that the diagnosis is correct and not confused with another type of the skin disorder which has a better prognosis, such as epidermolysis bullosa simplex. For such an action to be acceptable, the bad caused should not outweigh the good intended. The parents and the doctors wanted pain relief to be continued so that he should not suffer, but they also knew that increasing the dose would suppress his respiration. Here, giving morphine was intended to relieve pain but in the knowledge of the possibility of hastening death. While some people view such actions as equivalent to deliberately ending a life, others would disagree. The Working Party takes the view that, provided the treatment in this case has been guided by the best interests of the baby, and has been agreed through joint decision making, pain-relieving treatments are morally acceptable, even if potentially life-shortening (paragraph 2. However, unlike voluntary euthanasia in adults, which is sometimes defended on the grounds that competent adults have a basic right to exercise choice, a baby cannot let his or her wishes be known. Thus any decision to end life would be on the basis of what others judged to be his or her best interests. This case also raises the question (accepting that it is not permissible by law) of whether it is ever morally acceptable actively to end life. First, decisions about the care of the newborn take place by means of an accumulating series of conversations, observations and interactions, sometimes quite minor, that contribute to a final decision. In fact, a whole series of decisions need to be made, about what kind of care is given to a child at what stage and for how long. Consequently parents will often fear that they have not understood it well enough to provide a basis for properly considered, informed consent (see paragraph 2. Further, doctors may be selective in what they tell parents, even for the best of reasons (see paragraph 6. In conditions as rare as this form of epidermolysis bullosa, a specialist in palliative care would ideally be asked to advise the healthcare professionals looking after Freddie. Staff with these views might be inclined to present their advice in a way that leaves parents with little choice but to accept it. A study of 57 doctors reported that 58% preferred a joint approach to decision making and that only two thought that parents should take the full responsibility. The parents with whom we met59 were clear that, whatever the magnitude of the decision, it was one that they should take as parents, although in practice decisions were jointly taken, or made by the doctors. Nevertheless, it is entirely possible and even perhaps inevitable62 that when all concerned in a particular case believe that the parents were genuine partners in decision making, the parents may feel that they were led subtly towards a particular view. The balance of the information given, the tone of voice used, or the status of the person giving it can all be influential. However, these were parents who had expressed a wish to meet the Working Party and we acknowledge that other parents might feel differently. Those giving the information and advice are likely to be selective about what they impart. Ideally, nurses and doctors in a neonatal unit will provide immediate practical and emotional help at the time of death for bereaved families, as well as facilitating links to the community for longer-term support. For many severe disorders such as epidermolysis bullosa, specialist organisations can provide help. Most neonatal units offer parents assistance with funeral arrangements, the gathering and presentation of keepsakes, answering questions and providing information about the cause of death. They also offer leaflets and other general information about the grieving process. However, the law accepts a version of the doctrine of double effect that permits doctors to administer necessary pain relief even in doses that are known to have the incidental effect of shortening life. Having concluded our discussion of the types of decision that may need to be made for babies in intensive care treatment, we turn now to the broader question, of how more comprehensive and robust data can be gained on health outcomes. This information is crucial to enable doctors to provide more robust advice to parents on the prospects for individual cases. We noted in Chapter 5, that as the prospects for survival and outcomes for babies born at progressively earlier gestational ages improve, there is the possibility that the absolute number of survivors with some level of disability will increase. Significantly, the lack of information on health outcomes may become an increasing problem as advances in healthcare, medicines and technologies begin to improve the prospects of children with previously untreatable conditions. This includes, for example, children with cystic fibrosis, congenital birth defects, severe respiratory or heart conditions and cancers. The recommendations of the report emphasise the need for research to address these issues and for the encouragement of large-scale prospective studies. Follow up is needed not only for groups of children diagnosed with serious clinical problems around the time of birth or who are born at the borderline of viability, but also for children who have minor manifestations during this period but who are at potential risk of lateonset problems. We conclude that further clinical research of this type is needed to identify outcomes relating to the quality of life for the children affected and their families at different ages. Without improved data on outcomes, it will not be possible to give parents and healthcare professionals a more robust prognosis to help with decision making. Such data are also needed to improve current understanding of the relationship between clinical care and outcome. The availability of linked information of this kind would also encourage clinical trials and associated follow-up studies. The Working Party therefore takes the view that it is crucially important that the various existing datasets comprising clinical information collected at birth and subsequently during the neonatal period, should be integrated and linked. We note that training of healthcare professionals will be required to help ensure a consistent knowledge base for the identification and collection of the relevant data. A clinical dataset has been identified, based on a concise range of audit information around birth and aspects of neonatal care. Examples of the early data that we regard as important to collect include gestational age at birth as well as birthweight, clinical status and details of neonatal care. Other valuable information which could be recorded includes the use of preconception fertility treatment, as this is associated with multiple births, and consequently with prematurity (see paragraph 3. We recognise that, by their nature, data on outcomes may only partly reflect current practice by the time they are analysed. Nevertheless, there is, in the view of the Working Party, an ethical imperative to analyse outcomes for neonatal care. Normally, if information about patients is to be used for purposes beyond the delivery of personal treatment and care (as is the case when data are used for research), the consent of patients should be sought or the information should be anonymised.
Causes of dissatisfaction include unrealistic expectations from the elderly that they will sleep for as long as they did when they were younger bacteria 400x magnification discount flagyl 400 mg online, and from the sedentary that they will sleep as deeply as after exhausting physical activity antibiotic 5 days discount flagyl 250mg amex. It is well recognized that complaints of sleeping poorly are common antibiotics ointment for acne buy generic flagyl 200mg on-line, and occur in many psychiatric disorders antibiotic resistance paper flagyl 250 mg line, including depression, generalized anxiety, panic and phobia, hypochondriasis and with personality disorders. They are among the most frequent symptoms in anxiety-related disorders and affective disorders. Comparing those people with neuroses with a normal population, Jovanovic (1978) found that neurotic patients complained of more wakefulness in the frst third of the night; they spent more time lying awake in bed, they awoke during the night more frequently, they spent a relatively short period in deep sleep and their sleep was more likely to be impaired by unfamiliar surroundings. Those with major depressive disorder suffer from disturbed sleep, in which they take longer to fall asleep and spend less time asleep because of periods of wakefulness during the night and early morning wakening. Early insomnia, or diffculty in getting off to sleep, occurs in normal people who are aroused through anxiety or excitement. Their thoughts tend to dwell on the affect-laden experiences of the immediate past and also to rehearse ways of dealing with problems. Fatigue is experienced, but there is also a high level of arousal that prevents the necessary relaxation and withdrawal from perception that is required for sleeping. Late insomnia or early morning wakening is particularly characteristic of the depressive phase of affective disorders. The patient may wake frequently in the night after getting off to sleep satisfactorily and thenceforward sleep only ftfully and lightly. Alternatively, he may wake early in the morning and be unable to get to sleep again. The important characteristic of depression is that there is a marked change in sleep rhythm from the normal pattern for that person. In depression, the early morning wakening is often associated with marked diurnality of mood, with the most severe feelings of despondency and retardation occurring in the early morning. It is usually about seven to eight hours through the middle adult years but is markedly reduced from about 50 years of age onwards. These are often associated with abnormal experience in the sleepy state, such as hypnagogic and hypnopompic hallucinations (Chapter 7). Pseudohallucinations also occur, as does vivid imagery that is diffcult to distinguish from hallucination. Normally, passage into sleep is rapid and occurs passively rather than with active intention to sleep. Such patients may sleep for 17 hours or more and always require vigorous stimulation to wake them. These cases are more often seen by a neurologist than a psychiatrist and are reported only briefy here. In earlier accounts, the patient sleeps excessively by day and night but is rousable as from normal sleep. When awake, the patient eats voraciously (megaphagia) and may show marked irritability (Critchley, 1962). More recently it has become clearer that the condition is characterized by relapsing-remitting episodes of severe hypersomnia, cognitive impairment, apathy, derealization and psychiatric and behavioural disturbances. Just over half of patients have hyperphagia, are hypersexual (mainly boys), or have depressed mood (mainly girls), and about a third have other psychiatric symptoms such as anxiety, delusions or hallucinations. Although some symptoms are similar to those in patients with encephalopathy, imaging and laboratory fndings are unremarkable. Between episodes, patients generally have normal sleep patterns, cognition, mood and eating habits. During episodes, electroencephalography might show diffuse or local slow activity. Functional imaging studies have revealed hypoactivity in thalamic and hypothalamic regions, and in the frontal and temporal lobes (Arnulf et al. Narcolepsy is a form of hypersomnia and can occur either with or without cataplexy. Narcoleptic attacks are short episodes of sleep (10 to 15 minutes) that occur irresistibly during the day; they usually begin during adolescence and persist throughout life. Narcolepsy is often associated with cataplexy, during which the subject falls down because of sudden loss of muscle tone provoked by strong emotion. Hypnagogic hallucinations and sleep paralysis may also occur, but less commonly so. They occur between wakefulness and sleep, less commonly between sleep and wakening (hypopompic hallucination). Sleep paralysis is the inability to move during the period between wakefulness and sleep (in either direction). In the Pickwickian syndrome, named after the fat boy of the Pickwick Papers (Dickens, 1837), or more specifcally obstructive sleep apnoea, profound daytime somnolence is associated with gross obesity and cyanosis due to hypoventilation. Breathing is periodic during sleep and somnolence, with apnoeic phases that may last for up to a minute. Sustained drowsiness may occur with organic lesions of the midbrain or hypothalamus from various causes. The most important conditions giving rise to secondary hypersomnia are brain tumours, neurosarcoidosis and Niemann-Pick type C disease. There may be a state amounting to hysterical stupor, and other conversion symptoms may be present. Other patients with neurotic disorders complain persistently of daytime somnolence and an inability to concentrate. Sleepwalking is an example and consists of a series of complex behaviours arising during slow-wave sleep and resulting in walking during a period of altered consciousness. It is more characteristic of children than adults, and of males more than females. Activity is usually confned to aimless wandering and purposeless repetitive behaviour for a few minutes. The sleepwalker may reply mono-syllabically to questions, and there is little awareness of the environment, but injury is unusual. As sleepwalking occurs in deep sleep (stages 3 and 4), usually during the frst third of the night, it is unlikely to be the acting out of dreams. Night terrors also occur in deep sleep early in the night and often in the same individual who sleepwalks. Intense anxiety is manifested, the subject may shout and there is rapid pulse and respiration. It is not the same experience as a nightmare, because the latter is a type of dream, occurring in lighter states of sleep, and is remembered vividly if the person awakes immediately after the experience. Claims have been made that automatic, violent behaviour has taken place during a night terror. A person who commits a criminal act while asleep is not conscious of his actions and cannot be held legally responsible for them; the law calls this sane automatism (Fenwick, 1986; Ebrahim and Fenwick, 2010). During the nightmare itself, sleep paralysis will prevent violent emotions being acted on. For the act to be convincingly ascribed to night terror, neither the act nor its antecedent storyline should be remembered and all the evidence should point to the individual being asleep at the time. Previous evidence of night terror and sleep activity is important for corroboration. Less known are the reports of sexsomnia in which sexual behaviour occurs during sleep. Dreams How does phenomenology view dreams, their signifcance and their interpretationfi First, phenomenology can be concerned only with what is conscious; it cannot comment on that which is unconscious, although it may infer the existence of unconscious insofar as it explains some observed behaviours and phenomena. This has implications for the way in which the phenomenological approach will be used in therapy. Both by introspecting and by taking accounts from patients while actually dreaming, we know that memory is accurate and detailed, sometimes very detailed. Also, the process of reasoning is faultless, both for when bizarre elements intrude and also for when they do not. These bizarre elements, therefore, demonstrate neither defcient memory nor incapacity for rational thinking.
It requires public authorities to promote equality of opportunity for disabled people in the way they conduct their business antimicrobial jersey discount flagyl online mastercard. There remains a need for general education antibiotics kidney purchase flagyl 500 mg without prescription, to raise awareness about the nature and breadth of disability (Roberts et al virus yahoo email 250mg flagyl with amex. When determining if someone is disabled under the terms of the Act antimicrobial and antifungal discount 500 mg flagyl amex, any treatment or correction (such as a prosthesis) should not be taken into account (except glasses and contact lenses). It requires employers to make reasonable adjustments for a disabled person put at a substantial disadvantage by a provision, criterion or practice, or physical feature of the premises. However, as is witnessed from this list, the majority of accommodations that are described in the literature concern physical rather than psychiatric disabilities (MacDonald-Wilson et al. Barriers to providing accommodations for this group are identified as: resources, issues around disclosure, the attitudes of co-workers, and communication difficulties. Providing accommodations for people with a mental illness is often inexpensive, but they do require observation, fiexibility and good management (Pollet, 1995). Further American studies have suggested the following accommodations at work for people who have a mental health problem: r training of supervisors r modifications of the non-physical work environment (Fabian et al. The Disability Rights Commission has produced a comprehensive Code of Practice on Employment and Occupation (2004). It describes the duties of employers and others, and is intended to assist employers to prevent workplace disputes. It also helps to explain what the law means for disabled people and what they can do if they feel that they have been discriminated against. The Data Protection Act the Data Protection Act (1998) governs the use of personal information by businesses and organisations. Some information, such as a physical or mental health condition, is classified as sensitive information and is subject to tighter controls under the terms of the Act. Such information may only be used when there is an essential need to use it or where the individual has given their explicit consent. Therefore, you must ensure that you, as a health professional, ensure the confidentiality of the personal details which your client shares with you. It is important to discuss with the client what they are prepared to let their employer know about their health condition or disability. Employees may be fearful of revealing this type of information if they feel that it may jeopardise their job. Since the unscrupulous employer may indeed use this information for other purposes, their concerns may well have validity. There is far less risk of potential confiict between the two positions where a basic level of trust underpins the relationship between the client and their employer. For further information, the Data Protection Act can be found online at. The regulations cover recruitment, terms and conditions, promotions, transfers, dismissals and training. Laws must be interpreted, and so as each new case is brought before the courts it adds a further dimension to how that law is intended to be applied and understood. Having read through the laws and regulations which have been outlined above you will no doubt have recognised the need to strike a delicate balance. This balance must be, on the one hand, between the rights of any individual not to be discriminated against and to have every opportunity to participate in meaningful work. On the other, it concerns the duties placed on an employer to ensure that they adhere to robust working practices, for the health and safety of all employees as well as any members of the public who might be affected by their actions. Many occupational therapists may currently be unfamiliar with health and safety legislation, since it is seldom a core element of existing undergraduate programmes (Ross, 2006). However, you will see from the brief discussions above that there is an increasingly visible role for knowledgeable occupational therapists to assist employers to meet their obligations in this area. The Commission for Equality and Human Rights this Commission is still in the planning stages, and is expected to be created in the autumn of 2007. It will include the Disability Rights Commission, which we read about earlier, as well as two other existing equality commissions. The Industrial Injuries Advisory Council the Industrial Injury Disability Benefit Scheme is a state benefit which provides weekly compensation for people injured at work in industrial accidents and with certain prescribed diseases. It monitors and reviews new scientific evidence about certain diseases which may have an occupational link, and then decides whether the list of prescribed diseases, for which benefit may be paid, should be expanded or amended. For interested readers, the full list of diseases covered by the Industrial Injury Disability Benefit may be found at. They provide a range of training and work with employers and employees to resolve problems, such as disputes and disagreements at work. They will assist in the management of confiict, directed towards reaching an acceptable solution without involving, for example, an employment tribunal. They have produced recent guidance on age discrimination in the workplace (Advisory, Conciliation and Arbitration Service, 2006), and tackle discrimination and promoting equality (Advisory, Conciliation and Arbitration Service, 2005), which is concerned with any form of discrimination, including sex, race, disability, sexual orientation and religion. It focuses in particular on education, communication and the encouragement of co-operation between all persons and agencies involved in the provision of a healthy and safe working environment. We will briefiy consider the significant implications of impending policy changes, particularly with regard to benefits claimants with a disability. Thepoliticalspotlight remains firmly fixed on participation in employment as an integral part of an ongoing programme of welfare reforms. To this end, the Green Paper: A New Deal for Welfare: Empowering people to work (Department for Work and Pensions, 2006a), proposes a radical overhaul of the benefits system for new claimants. It builds on the changes introduced through the Pathways to Work programme, which, you may remember, includes Condition Management Programmes. These activities may include work-focused interviews with the personal advisor at the Jobcentre Plus, and participation in agreed programmes and activities which are work-related, or directed towards work return. Suitable activities may include attending a condition management programme or doing voluntary work. Attaching a financial inducement to promote return to work will, of course, have both advantages and disadvantages. It also means that a far more pro-active approach will be pursued in supporting people back to work. These are both positive steps and disabled workers themselves have indicated that, despite existing strategies and support, they need access to more structured, formalised and appropriate support (Roulstone et al. On the negative side, however, these planned reforms have significant resource implications if they are to be delivered effectively. The funding of these resources is yet to be clarified, although much of the provision will be out-sourced to the private and voluntary sector. In some parts of the country the infrastructure is not yet in place to deliver the agenda, therefore existing services may struggle to meet these targets. Additionally, details about the practical implementation of the reforms are currently limited. The conditional element of programme participation that will be attached to benefit payments has particular relevance to occupational therapists. As a result, the person may feel compelled to attend therapeutic interventions, such as Condition Management Programmes, rather than being there through personal choice. This compulsion may counterbalance the therapeutic benefits which a number of occupational therapists currently attribute to the voluntary nature of participation within existing programmes. It is important to refiect on the fact that these reforms are being delivered at a time when the economy is strong. What might the implications be, one wonders, for people with health conditions or disabilities who are expected to engage in work activity in a less than favourable economyfi Employers (Tehrani, 2004), insurers (Association of British Insurers, 2005) and personal injury lawyers (Association of Personal Injury Lawyers, 2004) are increasingly looking to healthcare and rehabilitation to meet their particular objectives. 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