[Costs of patient controlled analgesia in postoperative pain management in Germany]. / Kosten der patientenkontrollierten Analgesie (PCA) im Rahmen des postoperativen Schmerzmanagements in Deutschland.

PURPOSE: This systematic literature review was conducted to analyze the costs of postoperative patient controlled analgesia (PCA) in Germany. METHODS: The literature search comprised the search criteria "therapeutic procedure", "postoperative pain management", the routes of administration "intravenous PCA" (PCIA) and "epidural PCA" (PCEA), as well as their corresponding costs and economic analyses. RESULTS: Due to differences in indications, calculated costs and medical expenses it was not possible to compare the results from the respective studies. CONCLUSION: A critical examination of benefits and costs of therapeutic options in hospitals has become necessary with the implementation of the German DRG compensation system. This has created a substantial need for the optimization of resources and processes. There is an enormous demand for research on the costs for PCA in Germany. The identification of cost-driving factors is necessary to determine saving potentials and thereby develop new technologies for postoperative analgesia.

Added therapeutic value of memantine in the treatment of moderate to severe Alzheimer's disease.

When evaluating the added therapeutic value of a drug, evidence of greater overall benefit or at least an add-on benefit is increasingly being required. Therefore, cost-effectiveness in addition to clinical efficacy is an important consideration. The efficacy of a drug must be examined on the basis of clinical trials by measuring specific parameters that are affected by the drug (for example blood pressure with antihypertensive treatment). Today not only efficacy but also patient-relevant changes (patient benefits) must be demonstrated for a drug, often by measuring quality of life. In order to evaluate the benefit of monotherapy with the N-methyl-D-aspartate antagonist memantine in the management of moderate to severe Alzheimer's disease, a systematic literature review was conducted. The results showed a benefit for memantine in comparison with placebo in terms of a decrease in nursing care, a delay in care dependency and a delay in admission to nursing homes. In addition, an increase in quality of life has been observed.

Using at least 5x10(6)/kg CD34+ cells for autologous stem cell transplantation significantly reduces febrile complications and use of antibiotics after transplantation.

For autologous stem cell transplantation, it is common practice to infuse at least 2 x 10(6)/kg CD34+ cells to ensure rapid engraftment. However it was recently claimed that increasing the threshold to 5 x 10(6)/kg leads to a faster platelet engraftment. To evaluate these threshold values in our patient population we undertook a retrospective analysis of 127 autologous transplants performed at our institution between 1992 and 1998. Diagnoses included Hodgkin's and non-Hodgkin's lymphoma, myeloma, acute leukaemias and solid tumours. The transplant was peripheral blood stem cells in 107 cases and CD34-selected peripheral blood stem cells in 20 cases. The median number of transplanted CD34+ cells was 3.2 x 10(6)/kg (range 0.64-25.9 x 10(6)/kg). Haematopoietic recovery to a neutrophil count >0.5 x 10(9)/l took a median of 10 (range 5-16) days from transplant. When comparing patients receiving at least 5 x 10(6)/kg and 2-5 x 10(6)/kg CD34+ cells we found a significant reduction in the median number of days with fever (1 vs 3.5 days, P = 0.0025), incidence of fever (78.8 vs 92.1%, P = 0.032) as well as duration of antibiotic treatment (7 vs 10 days, P = 0.038). This was paralleled by a faster neutrophil recovery to 0.5 x 10(9)/l (9 vs 10 days, P = 0.047). There was no significant difference in the number of platelet or red cell transfusions between the two groups. We conclude that transplantation with a stem cell dose of at least 5 x 10(6)/kg CD34+ cells reduces infectious complications and should thereby increase the safety of this type of therapy while reducing duration (and cost) of antibiotic therapy. The transplantation threshold should thus not remain at 2 x 10(6)/kg particularly in patients with a good stem cell mobilisation capacity.

Autotransfusion systems (ATS).

Due to the large number of patients undergoing cardiac surgical procedures and the subsequent increase in demand for blood volume replacement, the use of autotransfusion is increasing in the postoperative setting. In a study conducted by Roche and Stengel it was estimated that the country's blood resources could be depleted by these surgical procedures. The use of autotransfusion offers a viable solution for this problem. Studies suggest that with autotransfusion, bank blood requirements may decrease as much as 50 percent. The ready availability and economic advantages associated with autotransfusion may also ensure continued use of systems of this type. It has been the authors' experience thus far that both systems presented have been safe and effective when used in postoperative management of the cardiac surgical patient.