A practical guide to medical ethics for intensivists.

This series of articles provides a practical guide to dealing with the complex ethical and legal challenges we face in the provision of Intensive Care. They explain the implications of recent legal rulings and cases (such as "Montgomery" and the tragic case of Charlie Gard), and include discussion of clinical scenarios with which we are all familiar. Each article is written by those who are not only experts in their fields, but who also deal with these issues on a day-to-day basis.

Survey of psychiatric assessment rooms in UK emergency departments.

Aims and method We aimed to estimate the proportion of UK emergency departments with a psychiatric assessment room and to determine whether such rooms met criteria for conducting high-risk assessments. Liaison psychiatry services were asked whether their hospital had such a room, whether it met the criteria and whether respondents judged it to be sufficiently safe and private. Results Of the 60 emergency departments included in the survey, 23% had a psychiatric assessment room that met all the safety criteria and was judged to be safe and private. Barriers to the establishment of an appropriate facility included it being a low priority for hospital management, a room being used for other purposes, and balancing safety requirements with the creation of a calming environment. Clinical implications Mental illness is a common reason for presentation to emergency departments. Despite national recommendations, this survey indicates that many departments lack a sufficiently safe and private assessment room, which compromises the safety and privacy of patient care.

London's liaison psychiatry services: survey of service provision.

Aims and method To describe the liaison psychiatry services of all 30 general hospitals in Greater London and to determine whether services met national recommendations. The results were compared with a similar survey conducted 8 years previously to determine whether there had been significant service development. Results We identified wide variations in service provision across London. Fifteen hospitals (50%) had 24-hour services and one had no service. There had been a significant increase in services that assessed older adults. Increases in the size of teams and consultant psychiatry staff were not significant. Clinical implications Despite an increasing emphasis on the effectiveness of liaison psychiatry services, no London hospital had staffing levels consistent with national recommendations. Recent evidence for the cost-effectiveness of liaison psychiatry and an emphasis on parity between physical and mental health in National Health Service policy may provide further impetus for growth.

Prevalence of anxiety and depression in osteoarthritis: use of the Hospital Anxiety and Depression Scale as a screening tool.

The aims of this study are to ascertain the prevalence of anxiety and depressive disorders in an outpatient population with osteoarthritis (OA), examine the interrelationships between severity of OA, pain, disability, and depression, and evaluate the Hospital Anxiety and Depression Scale (HADS) as a screening tool for this population. Patients with lower limb OA were evaluated with the Short Form McGill Pain and Present Pain Index Questionnaires, and a visual analogue scale, WOMAC Osteoarthritis Index-section C, and the HADS. Participants underwent a structured clinical interview by a liaison psychiatrist (AB). X-rays of affected joints were rated for disease severity. Fifty-four patients (42 females; mean age 63.3) were investigated. The prevalence of clinically significant anxiety and/or depression was 40.7% (95% confidence interval (CI), 27.6-55.0%). HADS was a good predictor of anxiety and depression with a sensitivity and specificity of 88% (95%CI, 64% to 99%) and 81% (95%CI, 65% to 92%), respectively. Pain correlated with HADS anxiety and depression scores (e.g. Rank correlation coefficients (Kendall's tau-b) between total HADS scores and Pain VAS scores 0.29; p=0.003). Disability was greater in patients with depression and/or anxiety (e.g. total HADS score; Kendall's rank correlation coefficient tau-b=0.26, p=0.007) OA severity as determined by radiological score was not a good predictor for anxiety nor depression and only weakly associated with disability. Anxiety and depression are very common in OA patients. HADS anxiety was a better predictor of diagnosed anxiety than HADS depression was of diagnosed depression. HADS is a valid and reliable screening instrument for detecting mood disorder, but not a diagnostic tool or a substitute for asking about symptoms of depression. The interrelationship between mental health, pain and disability is strong. We should therefore adopt a multidisciplinary approach to the management of OA.

Depression: diagnosis and management in terminal illness.

Depressive illness is often not recognized in terminally ill patients, because it is seen as an 'understandable' reaction. However, treating depression in such patients can significantly improve the quality of their remaining life. The diagnosis and management of depression in terminally ill patients will be discussed in this article.

Effect of medium-pressure UV irradiation on bromate concentrations in drinking water, a pilot-scale study.

This study investigated the potential for bromate removal from drinking water on irradiation with medium-pressure UV lamps-a technique gaining considerable interest for drinking water disinfection. Waters from two different sources were spiked with 20microg/L of bromate and irradiated with UV fluences up to 718mJ/cm(2) utilizing a pilot-scale reactor (Calgon Carbon Corp.) at a flow of 76L/min (20 gallon/min). Essentially no removal was observed in one of the source waters. Limited bromate removal, up to 19%, was observed in the second source water at high UV fluences (696mJ/cm(2)) and a fluence-response relationship was clearly evident. All removals would be negligible at UV fluences anticipated for drinking water disinfection (< or =40mJ/cm(2)). Different water characteristics, in particular competitive absorption by nitrate and possibly DOC, were most likely responsible for the differences in bromate removal in the waters tested. The source water that did not show any removal had a higher nitrate concentration (4 vs. 0.1mg N/L) and also a higher DOC concentration (4.1 vs. 3.1mg C/L) than the other source water which showed 19% bromate removal.