Outcome of clinical and subclinical myocardial injury in systemic lupus erythematosus - A prospective cohort study.

OBJECTIVES: To determine the outcome of subclinical lupus myocarditis (LM) over twelve months with regards to: mortality; incidence of clinical LM and change in imaging parameters (echocardiography and cardiac magnetic resonance [CMR]). To evaluate the impact of immunosuppression on CMR evidence of myocardial tissue injury. METHODS: SLE patients with and without CMR evidence of myocardial injury (as per 2009 Lake Louise criteria [LLC]) were included. Analysis at baseline and follow-up included: clinical evaluation, laboratory and imaging analyses (echocardiography and CMR). Clinical LM was defined as clinical features of LM supported by echocardiographic and/or biochemical evidence of myocardial dysfunction. Subclinical LM was defined as CMR myocardial injury without clinical LM. RESULTS: Forty-nine SLE patients were included with follow-up analyses (after 12 months) available in 36 patients. Twenty-five patients (51%) received intensified immunosuppressive therapy during follow-up for indications related to SLE. Disease activity (SLEDAI-2K) improved (p < 0.001) from 13 (median;IQR:9-20) to 7 (3-11). One patient without initial CMR evidence of myocardial injury developed clinical LM. Mortality (n = 10) and SLE clinical features were similar between patients with and without initial CMR myocardial injury. Echocardiographic left ventricular ejection fraction (LVEF) (p = 0.014), right ventricular function (p = 0.001) and wall motion abnormalities (p = 0.056) improved significantly but not strain analyses nor the left LV internal diameter index. CMR mass index (p = 0.011) and LVEF (p < 0.001) improved with follow-up but not parameters identifying myocardial tissue injury (LLC). A trend towards a reduction in the presence of CMR criteria was counterbalanced by persistence (n = 7) /development of new criteria (n = 11) in patients. Change in CMR mass index correlated with change in T2-weighted signal (myocardial oedema) (r = 386;p = 0.024). Intensified immunosuppressive therapy had no significant effect on CMR parameters. CONCLUSION: CMR evidence of subclinical LM persisted despite improved SLEDAI-2K, serological markers, cardiac function and CMR mass index. Subclinical LM did not progress to clinical LM and had no significant prognostic implications over 12 months. Immunosuppressive therapy did not have any significant effect on the presence of CMR evidence of myocardial tissue injury. Improvement in CMR mass index correlated with reduction in myocardial oedema and may be used to monitor SLE myocardial injury.

Financial incentives for antipsychotic depot medication: ethical issues.

BACKGROUND: Giving money as a direct incentive for patients in exchange for depot medication has proved beneficial in some clinical cases in assertive outreach (AO). However, ethical concerns around this practice have been raised, and will be analysed in more detail here. METHOD: Ethical concern voiced in a survey of all AO teams in England were analysed regarding their content. These were grouped into categories. RESULTS: 53 of 70 team managers mentioned concerns, many of them serious and expressing a negative attitude towards giving money for depot adherence. Four broad categories of ethical concern following Christensen's concept were distinguished: valid consent and refusal (n = 5), psychiatric paternalism (n = 31), resource allocation (n = 4), organisational relationships (n = 2), with a residual category others and unspecified (n = 11). DISCUSSION: The main concerns identified are discussed on the background of existing ethical theories in healthcare and the specific problems of community mental health and AO. Points for practice are derived from this discussion. A way forward is outlined that includes informed consent and an operational policy in the use of incentives, further randomised controlled trials and qualitative studies, and continuing discussions with all stakeholders, especially service users.

Research on mental disorders and their care in immigrant populations: a review of publications from Germany, Italy and the UK.

OBJECTIVE: The review aims to identify the extent and nature of research on mental disorders and their care in immigrant populations in three major European countries with high levels of immigration, i.e. Germany, Italy, United Kingdom (UK). METHOD: Peer-reviewed publications on the subject from the three countries between 1996 and 2004 were analyzed. The research questions addressed, the methods used, and the results obtained were assessed. RESULTS: Thirteen papers reporting empirical studies were found from Germany, four from Italy and 95 from the UK. Studies addressed a range of research questions and most frequently assessed rates of service utilization in different immigrant groups. The most consistent finding is a higher rate of hospital admissions for Afro-Caribbean patients in the UK. Many studies had serious methodological shortcomings with low sample sizes and unspecified inclusion criteria. DISCUSSION: Despite large scale immigration in each of the three studied countries, the numbers of relevant research publications vary greatly with a relatively high level of empirical research in the UK. Possible reasons for this are a generally stronger culture of mental health service research and a higher number of researchers who are themselves from immigrant backgrounds in the UK. CONCLUSION: Overall the evidence base to guide the development of mental health services for immigrant populations appears limited. Future research requires appropriate funding, should be of sufficient methodological quality and may benefit from collaboration across Europe.

[German-speaking mental health services research - what and how is reported? An analysis of publishing in Psychiatrische Praxis 1999-2002]. / Deutschsprachige psychiatrische Versorgungsforschung - Was und wie wird berichtet? - Eine Analyse von Veröffentlichungen in der Psychiatrischen Praxis 1999 - 2002.

OBJECTIVE: In mental health service research, the investigated services and care systems as well as the research methodology should be described in a precise and transparent fashion so that findings can be clearly interpreted and used. Therefore, this study investigates what is reported in German language publications on mental health service research. METHOD: All original papers on mental health service research, that were published in the Psychiatrische Praxis between 1999 and 2002, were systematically reviewed and, using a structured classification system, subjected to content analysis. In particular, it was assessed what forms of care had been studied and what characteristics of care were reported. RESULTS: 54 % (199) of all original publications reported mental health service research in a wide sense. Of these, 8 % were qualitative studies. 58 % of studies investigated in-patient treatment, 20 % comprehensive care systems, and 4 % services provided by psychiatrists or psychotherapists in private office practice. There were hardly any studies on innovative service models. In 51 % of studies, authors had conducted investigations within their own service or care system. In most articles characteristics of the patient sample were exactly described, whilst precise information on the researched service, such as funding, staffing and organisation, was usually missing. DISCUSSION: There still is relatively little research on outpatient services, and mental health service research is not yet appropriately based in the community. Requirements for exact and comprehensive descriptions of the researched services' and care systems are rarely met. In general, the findings suggest that mental health service research in German speaking countries might benefit from studies with researchers who are independent from the investigated service, the evaluation of innovative service models, and above all a standardised description of the services and context in research studies.