[Cost of Illness of HIV Patients under Anteretroviral Therapy in Germany - Results of the 48-Week Interim Analysis of the Prospective Multicentre Observational Study 'CORSAR']. / Krankheitskosten von HIV-Patienten unter antiretroviraler Therapie in Deutschland - Ergebnisse einer 48-Wochen-Interimsanalyse im Rahmen der prospektiven multizentrischen Kohortenstudie "CORSAR".

BACKGROUND: With the introduction of highly active combined antiretroviral therapy (c-ART) mortality and morbidity of HIV patients declined substantially. Earlier studies reported that c-ART was able to save health-care costs due to a reduction of other direct medical costs, particularly for inpatient treatments and concomitant medication. To date, analyses of costs and health-related quality of life (HRQOL) of patients under c-ART are lacking in Germany. Hence, this study aims to estimate the current cost of illness and HRQOL of HIV-patients under c-ART in different treatment lines. METHODS: A multicenter, prospective observational study was carried out in 12 specialised German centres for infectious diseases: 8 private practices/outpatient centres and 4 specialised hospitals offering both inpatient and outpatient services. Demographic, clinical and medication data were derived from patient records. Resource utilisation, information on productivity, out of pocket costs and HRQOL (EQ-5D) were collected every 12 weeks via a patient questionnaire. All costs were calculated based on price information from publicly accessible databases. RESULTS: N=1,154 patients were included in the analysis. Mean direct disease-related costs of -patients under c-ART amounted to 22,563 Euro/year. Patients beyond the 3(rd) line of treatment -incurred considerably higher costs 24,654 Euro/year. In the 1(st) treatment line, c-ART accounted for 83.2% of the total direct costs, in the 2(nd)/3(rd) line for 80.8% and in >3(rd) line for 83.4%, respectively. Indirect costs due to impaired productivity were higher in the 2(nd)/3(rd) treatment line (2,843 Euro) compared to the 1(st) (1,604 Euro) and >3(rd) (1,752 Euro) treatment lines, respectively. The average HRQOL (EQ-5D) varied between 0.77 (self-assessment via visual analogue scale) and 0.91 (utility score based on the German time trade-off tariff). CONCLUSIONS: Over the last decade, cost of illness of HIV patients under c-ART decreased slightly with average costs per year still being substantial. Main cost driver of overall costs is c-ART. There have been, however, noticeable shifts between different cost domains.

[Cesarean section with subsequent craniotomy in the area of the posterior cranial fossa]. / Sectio Caesarea mit anschliessender Kraniotomie im Bereich der hinteren Schädelgrube.

We report on a 31-year old pregnant patient with von-Hippel-Lindau syndrome who presented to the emergency room with symptoms of increased intracranial pressure. She was found in premature labour with a normal foetus of 29 weeks' gestational age in breech presentation. We discuss an anaesthetic and neurosurgical management during emergent craniotomy and Caesarean section. Caesarean section and posterior fossa craniotomy with resection of an angioblastoma are performed in one setting. Following rapid sequence induction with thiopentone and succinylcholine, anaesthesia is maintained with fentanyl, flunitrazepam and pancuronium; nitrous oxide and volatile anaesthetics are avoided. The advantages of this technique include haemodynamic stability and maintenance of intracranial pressure. Neonatal depression is likely with this technique and requires resuscitative measures. The indications for rapid sequence induction in pregnant patients with raised intracranial pressure at risk for aspiration are discussed. Different options for monitoring during this procedure are described.

Perioperative fluid and electrolyte management in children undergoing surgery for craniopharyngioma. A 10-year experience in a single institution.

In a retrospective study, the intra- and early postoperative data of 39 children with 46 operations for craniopharyngioma were analyzed. Diabetes insipidus (DI) occurred in 30 out of 32 cases without preoperative evidence of DI. We observed that all children who did not have a pituitary stalk preserved and 5 out of 7 patients with preserved pituitary stalk developed DI within 18 h of surgery. Short-term inappropriate secretion of antidiuretic hormone (SIADH) occurred in 2 children, but was quickly followed by DI. The time of onset of DI and SIADH did not correlate with sex, age, body weight, location of tumor, or duration or extent of surgery. Parenteral desmopressin was an effective treatment for intra- and postoperative DI. The duration of the clinical effect of desmopressin administration varied in different patients between 4 and 23 h. An approach to the immediate intra- and postoperative management of children with craniopharyngioma is presented.

Hemispheric CBF-alterations in the time course of focal and diffuse brain injury.

Hemispheric CBF-alterations were studied in the time course of focal and diffuse-brain injury in a series of 25 head injured patients. Repeated 133 Xe CBF measurements with a mobile 10 detector system were performed in order to evaluate hemispheric CBF and cerebral vasoreactivity after change of PaCO2. Focal brain injury influenced hemispheric CBF varying in the time course: A hyperperfusion could be found within the first seven days after injury in 55 percent, whereas a hypoperfusion could be detected during the whole examination period in 18 percent. In diffuse injury we never saw such CBF abnormalities. On the other hand hemispheric CO2-reactivity was disturbed in focal and diffuse lesions, whereas a correlation between altered CBF at rest and CO2-reactivity could be only detected in 40% in focal injury. This investigations demonstrates no significant general, however, a partial influence of morphological damage upon cerebral microcirculation.