[Standardized documentation of health-related quality of life in patients with psoriatic arthritis : Validation of the German version of the psoriatic arthritis quality of life (PsAQoL) questionnaire]. / Standardisierte Erfassung der gesundheitsbezogenen Lebensqualität bei Patienten mit Psoriasisarthritis : Validierung der deutschen Version des "Fragebogen zur Lebensqualität von Patienten mit Psoriasisarthritis (PsAQoL)".

BACKGROUND: The standardized assessment of health-related quality of life is becoming increasingly more important. The English questionnaire on psoriatic arthritis quality of life (PsAQoL) is a disease-specific instrument for measuring the quality of life of patients with psoriatic arthritis (PsA). The aim of the present study was to translate the PsAQoL into German and to validate the German version in a cohort of PsA patients recruited from routine care. METHOD: The translation and validation of the PsAQoL questionnaire was carried out in a stepwise procedure involving affected patients with PsA. After translation of the original English questionnaire the German version was evaluated in a field test. The psychometric features of the questionnaire were then examined in a PsA cohort from routine care. In addition to the construct and group validity, the reliability of the questionnaire was tested using test-retest reliability and internal consistency. The physical functioning was measured with the health assessment questionnaire (HAQ) and domains of the quality of life with the Nottingham health profile (NHP). RESULTS: In a field test with 10 patients the German version of the PsAQoL questionnaire proved to be relevant, easily understandable and feasible (processing time 4.7 ± 2.1 min). A total of 126 patients (37.3% male, age 55.6 ± 11.3 years) were included in the validation cohort. The PsAQoL showed moderate correlation with the HAQ (r = 0.65) and moderate to good correlation with the NHP (subdomains r = 0.58-0.75). The internal consistency was high (Cronbach's α 0.92) and reliability in patients with stable disease course was very good (Spearman correlation coefficient 0.94). The PsAQoL can differentiate between different patient groups. CONCLUSION: The German translation of the PsAQoL provides a valid disease-specific instrument for the standardized assessment of health-related quality of life in patients with PsA. The psychometric characteristics of this questionnaire are comparable with the original English version. The German PsAQoL can therefore be recommended for clinical and scientific application.

Warming weather changes the chemical composition of oat hulls.

The current threats of climate change are driving attention away from the petrochemical industry towards more sustainable and bio-based production processes for fuels and speciality chemicals. These processes require suitable low-cost starting material. One potential material assessed here is the oat hull. Its overall chemical composition has so far not been fully characterized. Furthermore, it is not known how it is affected by extreme weather events. Oat hulls (Kerstin and Galant varieties) grown during 'normal' weather years (2016 and 2017) are compared to the harvest of the warmer and drier year (2018). Standard methods for determination of plant chemical composition, with focus on carbohydrate composition, are utilized. Oat hulls grown in 'normal' weather conditions (2017) are rich in lignocellulose (84%), consisting of 35% hemicellulose, 25% lignin and 23% cellulose. Arabinoxylan was found to be the major biopolymer (32%). However, this composition is greatly influenced by weather variations during the oat growth phase. A lignocellulose reduction of 25% was recorded in the warmer and drier 2018 harvest. Additionally, a 6.6-fold increase in starch content, a four-fold increase in protein content and a 60% decrease in phenolic content was noted. Due to its high lignocellulose composition, with an exceptionally large hemicellulose fraction, the chemical composition of oat hulls is unique among agricultural by-products. However, this characteristic is significantly reduced when grown in warmer and drier weather, which could compromise its suitability for use in a successful biorefinery.

A value proposition for trough level-based anti-TNFα drug dosing.

Treatment of inflammatory bowel diseases and rheumatic disorders with anti-tumor necrosis factor alpha (TNFα) drugs is expensive, while a significant proportion of patients does not show adequate clinical response. Therapeutic drug monitoring (TDM) enables patient-specific anti-TNFα therapy. The role of laboratory tests in clinical care has recently been described in a value proposition framework. It describes care processes, stakeholders, costs, risks, benefits and patient outcomes based on the use of a laboratory test in a clinical care pathway. We have applied this concept to the use of TDM for anti-TNFα drugs, describing evidence that supports the intervention and its cost effectiveness, steps that need to be adjusted in the care pathway, possible treatment algorithms and measures to assess adoption of this framework into clinical practice. For effective TDM, an assay for measurement of drug levels together with appropriate target ranges and an anti-drug-antibody assay have to be implemented. Also, instead of only reporting the drug concentration, laboratorians, pharmacists and clinicians should deliver added value by introducing a TDM-based treatment algorithm into clinical practice. Thus, to maximize effectiveness of TDM of anti-TNFα therapy in routine care, adjustment of current care pathways and cooperation of many stakeholders are needed.

Switching from infliximab innovator to biosimilar in patients with inflammatory bowel disease: a 12-month multicentre observational prospective cohort study.

BACKGROUND: Infliximab biosimilars have become available for treatment of inflammatory bowel disease (IBD). However, data showing long-term safety and effectiveness of biosimilars in IBD patients are limited. AIM: To study prospectively the switch from infliximab innovator to biosimilar in an IBD cohort with 12 months follow-up to evaluate safety and effectiveness. METHODS: Adult IBD patients from two hospitals treated with infliximab innovator (Remicade; Janssen Biotech,  Horsham ,  Pennsylvania, USA) were switched to infliximab biosimilar (Inflectra; Hospira, Lake Forest, Illinois, USA) as part of routine care, but in a controlled setting. Blood samples were taken just before the first, second, fourth and seventh infusion of biosimilar. Infliximab trough levels, antibodies-to-infliximab (ATI), CRP and ESR were measured and disease activity scores were calculated. RESULTS: Our cohort consisted of 133 IBD patients (64% CD, 36% UC). Before switching we found widely varying infliximab levels (median 3.5 µg/mL). ATI were detected in eight patients (6%). Most patients were in remission or had mild disease (CD: 82% UC: 90%). After switching to biosimilar, 35 patients (26%) discontinued therapy within 12 months, mostly due to subjective higher disease activity (9%) and adverse events (AE, 9.8%). AE included general malaise/fatigue (n = 7), arthralgia (n = 2), skin problems (n = 2) and infusion reactions (n = 2). No differences in IFX levels, CRP, and disease activity scores were found between the four time points (P ≥ .0917). CONCLUSIONS: We found no differences in drug levels and disease activity between infliximab innovator and biosimilar in our IBD cohort, indicating that biosimilars are safe and effective. The high proportions of discontinuers were mostly due to elective withdrawal or subjective disease worsening.

Therapeutic drug monitoring (TDM) as a tool in the switch from infliximab innovator to biosimilar in rheumatic patients: results of a 12-month observational prospective cohort study.

The objective of this study is to apply therapeutic drug monitoring (TDM) as an objective tool to monitor the switch from infliximab innovator (INX) to infliximab biosimilar (INB) in our diverse rheumatic cohort in daily clinical practice. All rheumatic patients on INX treatment (Remicade®) and ≥18 years were switched to INB (Inflectra®) as part of routine care, but in a controlled setting. Patients were monitored by taking blood samples just before the first infusion of INB (T1), and after the second (T2), fourth (T3), and seventh (T4) infusion of INB. T4 reflects the patients' status after ∼12 months. Infliximab trough levels, antibodies-to-infliximab (ATI), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and validated disease activity scores (if possible) were measured. Our population consisted of 27 patients with seven different rheumatic diseases who had received INX for 143 (58-161) months (median (IQR)). Half of the patients (52%) received concomitant immunosuppressives. We found widely varying infliximab levels, with only 56% within the proposed therapeutic range of 1-5 µg/mL. One patient had very high ATI levels (>880 au/mL), and two had low ATI levels (≤30 au/mL). After switching to INB, seven patients (26%) discontinued the therapy, partially due to subjective reasons. No difference in infliximab levels, CRP levels, and disease activity scores was found between the four time points (p ≥ 0.2460). In conclusion, no pharmacokinetic or clinical differences were found between INX and INB in our diverse rheumatic cohort. TDM is a helpful tool to monitor patients switching from INX to INB.

[Rare presentation of a scleral nevus with progression in size]. / Seltene Präsentation eines skleralen Nävus mit Größenprogredienz.

A 52-year-old male caucasian patient presented with a limbal subconjunctival pigmentation of unknown origin with progressive enlargement over the past years. Differential diagnoses included a malignant melanocytic lesion; therefore, an excisional biopsy was performed. Prior investigations showed no ciliary body or anterior chamber angle involvement. Histological and immunohistochemical analysis revealed the rare diagnosis of a scleral nevus. The clinical, histological and immunohistochemical findings as well as the relevant differential diagnoses are discussed.

Determination of dabigatran and rivaroxaban by ultra-performance liquid chromatography-tandem mass spectrometry and coagulation assays after major orthopaedic surgery.

Major orthopaedic surgery is associated with an increased risk of venous thromboembolism. Direct oral anticoagulants (DOACs) are recommended as thromboprophylactic agents after orthopaedic surgery. Although routine monitoring of DOACs in general is not required, measuring DOAC concentration may be necessary in clinical settings. The effects of DOACs on routine coagulation assays in spiked material are studied extensively, however, few data are available on DOAC concentration in patients after major orthopaedic surgery. We measured trough and peak DOAC concentrations with UPLC-MS/MS and routine coagulation tests in a prospective study including 40 patients receiving thromboprophylactic treatment with dabigatran 220mg od and 40 patients receiving rivaroxaban 10mg od after major orthopaedic surgery. For rivaroxaban, the median trough concentration with UPLC-MS/MS was 17.1ng/mL and median peak concentration was 149ng/mL. The anti-Xa assay displayed a good correlation, but a positive bias in comparison to the reference method. Furthermore, trough levels were mostly below the LOD of the anti-Xa assay. For dabigatran, the median trough concentration with UPLC-MS/MS was 12.1ng/mL, and median peak level was 80.8ng/mL. A positive bias was found when results from coagulation assays were compared to UPLC-MS/MS data. However, the addition of glucuronidated metabolites to dabigatran concentration UPLC-MS/MS data generally resolved most of this bias. Age was found to have a significant influence on dabigatran pharmacokinetics, irrespective of kidney function, whereas no effect of age was found during rivaroxaban treatment. In both treatment groups, female subjects displayed faster pharmacokinetics in comparison to male subjects, although not reaching significance. We conclude that UPLC-MS/MS is the method of choice to measure trough concentrations of DOACs in patients after orthopaedic surgery. Current coagulation assays are not suited for this purpose. We found large heterogeneity in both peak and trough concentrations of DOACs, and showed that pharmacokinetics of novel oral anticoagulants may be influenced by age and gender. Whether patients with high or low trough concentrations are at increased risk for bleeding or thromboembolic events respectively remains to be established.

Determination of dabigatran, rivaroxaban and apixaban by ultra-performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) and coagulation assays for therapy monitoring of novel direct oral anticoagulants.

BACKGROUND: Three novel direct oral anticoagulants (DOACs) have recently been registered by the Food and Drug Administration and European Medicines Agency Commission: dabigatran, rivaroxaban, and apixaban. To quantify DOACs in plasma, various dedicated coagulation assays have been developed. OBJECTIVE: To develop and validate a reference ultra-performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) method and to evaluate the analytical performance of several coagulation assays for quantification of dabigatran, rivaroxaban, and apixaban. METHODS: The developed UPLC-MS/MS method was validated by determination of precision, accuracy, specificity, matrix effects, lower limits of detection, carry-over, recovery, stability, and robustness. The following coagulation assays were evaluated for accuracy and precision: laboratory-developed (LD) diluted thrombin time (dTT), Hemoclot dTT, Pefakit PiCT, ECA, Liquid anti-Xa, Biophen Heparin (LRT), and Biophen DiXal anti-Xa. Agreement between the various coagulation assays and UPLC-MS/MS was determined with random samples from patients using dabigatran or rivaroxaban. RESULTS: The UPLC-MS/MS method was shown to be accurate, precise, sensitive, stable, and robust. The dabigatran coagulation assay showing the best precision, accuracy and agreement with the UPLC-MS/MS method was the LD dTT test. For rivaroxaban, the anti-factor Xa assays were superior to the PiCT-Xa assay with regard to precision, accuracy, and agreement with the reference method. For apixaban, the Liquid anti-Xa assay was superior to the PiCT-Xa assay. CONCLUSIONS: Statistically significant differences were observed between the various coagulation assays as compared with the UPLC-MS/MS reference method. It is currently unknown whether these differences are clinically relevant. When DOACs are quantified with coagulation assays, comparison with a reference method as part of proficiency testing is therefore pivotal.

[Parameters of quality for aortic valve replacement]. / Qualitätsparameter für den Aortenklappenersatz.

Advantages and disadvantages of mechanical or biological heart valve prostheses in combination with complications during long-term follow-up are responsible for the quality of aortic valve replacement. Anatomical conditions like narrow aortic root, concomitant coronary artery disease or reduced left ventricular function impair the quite good surgical results necessitating surgical intervention or the use of stentless valve implants.

Omega-3 fatty acids-loaded lipid nanoparticles for patient-convenient oral bioavailability enhancement.

Omega-3 fatty acids are commonly used as food supplements not only for their positive effects on the blood lipid profile but also for their cardioprotective properties. The majority of the commercially available products is made out of fish oil. Apart from the unpleasant side effects, up to 10 capsules per day have to be taken by the patients. This article describes the development and characterisation of an alternative lipid nanoparticle delivery system, which has the potential to reduce side effects and enhance bioavailability.

Tissue-specificity of apoptosis in hepatoma-derived cell lines.

Apoptosis is known to play a critical role in development and homeostasis in metazoans. Although apoptotic responses vary widely among cell types, the underlying mechanisms responsible for these differences are not known. In order to understand the molecular basis for these differences, we have studied a cell culture model comparing hepatoma cells to dedifferentiated cell lines derived from them. We recently reported evidence suggesting that a common regulatory locus affects both liver-specific function and sensitivity to lipopolysaccharide (LPS)-mediated apoptosis. Here, we show that dedifferentiated hepatoma cells undergo apoptosis in response to multiple compounds, including sorbitol (to induce hyperosmotic shock), TNF alpha and the microtubule damaging agent vinblastin. In contrast, the hepatoma parental cells fail to undergo apoptosis in response to any of the compounds tested. Further analysis of LPS-mediated cell death found that antioxidants N-acetylcysteine and alpha-tocopherol partially prevented apoptosis. Lastly, evidence is presented showing that LPS-mediated cell death of the hepatoma variant cell lines is caspase-dependent. These results suggest that pathways dictating hepatic phenotype also affect general cellular survival mechanisms in response to multiple agents. The dedifferentiated cells provide a model to examine the influence of cell-type specific expression on apoptotic signaling.

Long-term effectiveness of operative procedures for stanford type a aortic dissections.

BACKGROUND: The object was to evaluate the long-term effectiveness of strategies for managing the aortic root and distal aorta in type A dissections. METHODS: From 1990 to 1999, 50 patients (32 men (64.07%); 18 women, (36.0%); mean age 57.4 +/- 11.1 years) underwent operation for ascending aortic dissection. Surgical strategies included aortic root replacement with a composite graft (21/50; 42.0%), valve replacement with supracoronary ascending aortic graft (3/50, 6%), and valve preservation or repair (26/50; 52.0%). RESULTS: Overall hospital mortality rate was 18.0%. Follow-up was completed for 47 patients (94.0%) and ranged from 1 month to 10.5 years (mean 28.8 months). Actuarial survival for patients discharged from the hospital was 84% at 1 year, 75% at 5 years, and 66% at 10 years. There was no significant difference between the various procedures regarding mortality, neurological complications, long-term survival, and proximal reoperations. The ascending aorta alone was replaced in 8 of 50 patients (16%), ascending and hemiarch in 30 of 50 patients (60%), and arch and proximal descending aorta in 12 of 50 patients (24%). Hospital mortality (11.5%, 20.0%, and 16.7%, respectively; p > 0.05) and 5- and 10-year survival (p > 0.05) were not statistically dependent on the extension of the resection distally. Residual distal dissection was not associated with a decrease in late survival. With regard to emergency surgery (36/50) there was no significant difference in hospital mortality (p > 0.05) and 5-year survival (p > 0.05) between those who had undergone coronary angiography (19/36; 52.8%) on the day of surgery with those who had not (17/36; 47.2%). CONCLUSIONS: Preservation or repair of the aortic valve can be recommended in the majority of patients with type A dissection. Distal extension of the resection does not increase surgical risk. Residual distal dissection does not decrease late survival. Preoperative coronary angiography may not affect survival in patients undergoing emergency surgery.

[Management system for patients requiring stereotactic macrobiopsies of the breast: report on 100 patients]. / Mise en place de la prise en charge des macrobiopsies stéréotaxiques mammaires: évaluation sur 100 patientes.

PURPOSE: The authors describe and evaluate the management system for patients requiring large core vacuum-assisted biopsies at a dedicated breast center. This process includes mandatory review of all requests by a multidisciplinary team. MATERIAL: and method. Patients were provided questionnaires to evaluate their degree of satisfaction with the management process. Results from biopsy and surgery were retrospectively reviewed. RESULTS: From the 100 patients included in the study (106 macrobiopsies), 95,28% of biopsies were informative. The degree of correlation between the histological diagnosis from biopsy and surgery was 86,95% for the 46 operated cases. The degree of acceptability by patients as well as medical and non-medical staff was satisfactory. CONCLUSION: The original feature of this process is the retrospective review of all charts after the histological results becomes available for final validation of the biopsy results and management. The results of the biopsy and the post biopsy management are provided by the initial referring physician, allowing optimal patient care and follow-up.

Long-term effectiveness of operative procedures for Stanford type A aortic dissections.

BACKGROUND: To evaluate long-term effectiveness of strategies for managing the aortic root and distal aorta in type A dissections. METHODS: From 1990 to 1999, 50 patients (32 men, 64.07%; 18 women, 36.0%; mean age 57.4 y +/- 11.1) underwent operation for ascending aortic dissection. Surgical strategies included aortic root replacement with a composite graft (21/50; 42.0%), valve replacement with supracoronary ascending aortic graft (3/50, 6%), and valve preservation or repair (26/50; 52.0%). RESULTS: Overall hospital mortality rate was 18.0%. Follow-up was completed for 47 patients (94.0%) and ranged from 1 month to 10.5 years (mean 28.8 months). Actuarial survival for patients discharged from the hospital was 84% at 1 year, 75% at 5 years, and 66% at 10 years. There was no significant difference between the various procedures regarding mortality, neurological complications, long term survival and proximal re-operations. The ascending aorta alone was replaced in 8/50 patients (16%), ascending and hemiarch in 30/50 patients (60%) and arch and proximal descending aorta in 12/50 patients (24%) Hospital mortality (11.5, 20.0 and 16.7% respectively; p > 0.05) and 5- and 10-year survival (p > 0.05) were not statistically dependent on the extension of the resection distally. Residual distal dissection was not associated with a decrease in late survival. With regard to emergency surgery (36/50) there was no significant difference in hospital mortality (p > 0.05) and 5 year survival (p > 0.05) between those who had undergone coronary angiography (19/36; 52.8%) on the day of surgery with those who had not (17/36; 47.2%). CONCLUSIONS: Preservation or repair of the aortic valve can be recommended in the majority of patients with type A dissection. Distal extension of the resection does not increase surgical risk. Residual distal dissection does not decrease late survival. Preoperative coronary angiography may not affect survival in patients undergoing emergency surgery.

[CD-ROM burning of CT scan images: initial experience]. / Mise en place d'un système de gravure d'examens scanographiques sur cédérom.

OBJECTIVES: To evaluate the cost, the functionment and the impact of the installation of a CD-ROM burning system of CT scan images. MATERIALS AND METHODS: An automated CD-ROM burning system (e-patient*, TSI, Paris, France) allows to burn CDs for CT scan examinations containing more than 4 films. During a 3 month period, we have delivered for each examination a CD-ROM including images with a Dicom viewer and a selection of interesting images printed on one film. The system has been evaluated by the technologists, the radiologists and the referring physicians by means of a questionnaire. The costs and the technical problems have also been studied. RESULTS: The benefits of our system are the increase of the diagnostic performances of the referring physicians who use the DICOM format and a reduction of the printing costs. All referring physicians pointed out major changes in their daily work including difficulties to visualize images in relation with a lack of computer infrastructure and the impossibility of simultaneous analysis of several examinations. Technologists encountered technical problems to bum examinations and radiologists had to do extra work to related to image selection. CONCLUSION: The installation of an automated burning system requires the creation of a dedicated team to train all the users and adapt the presentation of results to the clinical constraints (i.e. performing and printing an image selection). This system will not replace the hospital network but will be complementary.

Assessment of left mammary artery grafts (LIMA) to left anterior descending artery (LAD) after off-pump coronary artery bypass grafting by color Doppler.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) on a beating heart with a LIMA graft to the LAD is established for patients with one vessel disease. The aim of the study was to assess the LIMA patency noninvasive by transcutaneous duplex ultrasound. METHODS: 25 patients (16 male, 9 female, mean age 58+/-13 yr) with LIMA grafts to LAD by OPCAB procedures were studied 7-20 days after surgery. Doppler velocity parameters were measured by use of a 7 MHz transducer placed in left intercostal space. The conventional coronary angiographies performed showed the LIMA graft patent. RESULTS: In all cases a typical biphasic pattern of blood flow was recorded with forward flow in both systole and diastole respectively. Under basal conditions the mean peak velocities in systole were 0.36 m/s and the mean peak velocities in diastole were 0.27 m/s with a mean systolic/diastolic ratio of 1.33. CONCLUSION: Transcutaneous Doppler ultrasound is useful in the detection of the LIMA graft flow. This non-invasive technique may find applications for routine postoperative follow-up of patients with LIMA grafts.

Surgical glove perforation in cardiac surgery.

BACKGROUND: Recently, concern for the protection of health care employees and health care recipients has led to increasing awareness of transmitted infections. Sterile surgical gloves were tested to determine the incidence of perforations after being worn during procedures commonly performed by cardiac surgeons. MATERIAL AND METHODS: In a prospective study conducted from January 15, 2000 through February 15, 2000, 953 gloves worn during cardiac surgery were evaluated for punctures. Pairs of sterile latex surgical gloves were collected over a period of one month. Routine tasks included mainly bypass and valve surgery. Impermeability was tested by means of a water retention test according to European standard EN 455 Part 1 performed on 954 (Manufix, Hartmann, Germany) latex gloves. A control group of 50 unused gloves was also evaluated for the presence of spontaneous leakage. Gloves were separated according to whether the wearer was an operator (254 gloves), first assistant (220 gloves), second assistant (272 gloves), or theatre nurse (207 gloves). Gloves with a known perforation occurring during the procedure were not included in the study. RESULTS: There were no punctures in the 50 unused gloves. Punctures were detected in 66 of 254 (26.0 %) gloves used by operators, 49 of 220 (22.3 %) used by first assistants, 25 of 272 (9.2 %) used by second assistants, and 78 of 207 (37.7 %) used by theatre nurses. Some gloves had more than one puncture, accounting for the 244 holes detected (operators 75/244 = 30.7 %; first assistants 54/244 = 22.1 %; second assistants 28/244 = 11.5 %; theatre nurses 87/244 = 35.7 %). Sites of scalpel and suture needle injuries were most commonly the thumb (27.3 %) and pointer finger (42.1 %) of the non-dominant hand, followed by, in descending order: middle finger (10.2 %), other fingers (15.7 %), palm (3.8 %) and back of the hand (0.9 %). CONCLUSION: The number of punctures that occur during cardiac operations is obviously higher than has so far been assumed. Therefore, cardiac surgeons should consider the incidence of unknown glove perforations when planning surgery in patients with infectious diseases.

[Psychosomatic disease in female teachers. Social context, contents and perspectives of inpatient treatment with a goal of rehabilitation and return to work]. / Psychosomatische Erkrankungen bei Lehrerlnnen. Sozialer Kontext, Inhalte und Perspektiven stationärer Behandlungen im Hinblick auf die Wiederherstellung der Arbeitsfähigkeit.

Despite the considerable consequences, school teachers treated in psychosomatic in-patient settings, have not yet been the subject of investigations. Whether, for whom and which kind of job related treatment can be helpful for teachers returning to work can only be discussed if the specific stress and the social situation of teachers as public officials ("Beamtenstatus") are taken into consideration. On this point of view a systematic evaluation of 63 psychosomatically ill teachers consecutively admitted in a psychosomatic hospital was performed. The average age was 50, suffering mostly from depression or/and tinnitus. Most teachers rated job related stress as influencing their symptomatologies. A program focusing on discrepancies between personal ideals versus real situations in school, problems in social interactions and time management, should be a valuable part of the teachers' psychosomatic inpatient treatment. This approach was affected by a strong desire for early retirement in about half of the teachers.

Depression and schizophrenia in epilepsy: social and biological risk factors.

BACKGROUND: In a retrospective study we investigated the role of social and biological risk factors for the development of major depression and schizophreniform psychoses in epilepsy. We tested the hypotheses that social risk factors are associated with depression and biological risk factors are associated with schizophreniform psychoses. METHOD: We studied 25 patients with epilepsy and paranoid-hallucinatory psychosis, 25 patients with epilepsy and major depression, and 50 non-psychiatric epilepsy patients (controls) with respect to biological and psychosocial variables. RESULTS: Schizophrenic patients had an earlier age of onset of epilepsy and a more severe epilepsy as characterised by history of status epilepticus, multiple seizure types and severity of seizures compared to non-psychiatric controls. Simple seizure symptoms were often vegetative and EEGs showed various abnormalities including temporal lobe discharges but no lateralisation to either side. With respect to antiepileptic drugs (AED) there were only few significant differences between groups: Polytherapy as well as treatment with phenytoin (DPH) was more frequent in psychotic patients as compared to non-psychiatric patients. Patients with psychoses were also characterized by a disturbed familial background, lack of interpersonal relationships, social dependency and professional failure. Depressive patients were significantly older than non-psychiatric controls and they suffered more frequently from focal epilepsies arising from the temporal lobe. They did not differ from controls with respect to severity of epilepsy. Treatment with valproate (VPA) was inversely linked with depression, suggesting that VPA may have prophylactic antidepressive properties in epilepsy patients. There were no psychosocial variables significantly linked with depression. CONCLUSIONS: In this study, patients with different forms of psychiatric complications in epilepsy could clearly be distinguished from controls. However, we could not confirm the simple hypothesis that there are biological predictors for schizophreniform psychoses and psychosocial predictors for major depression. Neurological and sociological variables seem linked with both, suggesting a multifactorial etiology.