Enhanced recovery after surgery: the future of elective arthroplasty?

Summary: Enhanced recovery after surgery is a method of streamlining the patient journey pre-, intra- and post-operatively in order to account for foreseeable and unforeseeable barriers to recovery. Originally pioneered in general surgery, the technique has been adopted in other specialities, given its potential to minimise the duration of hospitalisation, hasten recovery and improve patient experience. Enhanced recovery programmes are of particular interest in orthopaedic surgery, where patients who often have multiple comorbidities could gain substantial benefits from more efficient management. This is particularly pertinent given the rising prevalence of age-related joint disease requiring arthroplasty: Enhanced Recovery is more economically and clinically efficient. Relevance: Enhanced recovery is a relatively novel - heterogeneously implemented – method of managing the surgical patient journey. Intrinsic to the success of such programmes is a thorough understanding of its components and close communication within the multidisciplinary team. Medical students’ understanding of what these protocols involve will significantly affect their management of foreseeable – and unforeseeable – barriers to success in elective surgical patients during clinical years and in their future practice. It is therefore essential that all medical students – whether they have an interest in a surgical career or not – have a grounding in the components of enhanced recovery, because such programmes will form part of their practice at some point in their careers. Take-home message: Enhanced recovery is a proactive intervention, which has been shown to be extremely effective across a number of surgical disciplines in reducing length of stay, whilst maximising postoperative outcomes. Trainees would benefit from a detailed knowledge of enhanced recovery programmes in order to provide a higher standard of care during their encounters with patients at every stage of the surgical pathway

The Informal Sector In Francophone Africa: Firm Size, Productivity, And Institutions

This book is a major step towards improving the understanding of the complex reality of informal sector firms in francophone West Africa. It innovates by concentrating on informal firms rather than informal employment (as other studies do), and identifying \u27large informal\u27 sector firms whose sales rival those of large formal-sector firms but operate in ways that are similar to small informal operators. Not only is the regulatory environment facing these two types of informal firms distinct, but policies aimed at improving their productivity need to be differentiated. This study focuses on the urban informal sector in three capital cities: Dakar (Senegal), Cotonou (Benin), and Ouagadougou (Burkina Faso). The study also breaks new ground with an eclectic methodology and primary data collection. Quantitative and qualitative firm-level data were collected involving a unique and fruitful collaboration among academic researchers, government officials, the West African economic and monetary union commission, informal and formal sector business associations, and labor unions. This volume represents the culmination of a long collaboration between the Centre de Recherches Economiques Appliquees (CREA) at the University Cheikh Anta Diop of Dakar and the World Bank

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

Real-world experience with caplacizumab in the management of acute TTP

The cornerstone of life-saving therapy in immune-mediated thrombotic thrombocytopenic purpura (iTTP) has been plasma exchange (PEX) combined with immunomodulatory strategies. Caplacizumab, a novel anti–von Willebrand factor nanobody trialed in 2 multicenter randomized controlled trials (RCTs) leading to European Union and US Food and Drug Administration approval, has been available in the United Kingdom (UK) through a patient access scheme. Data were collected retrospectively from 2018 to 2020 for 85 patients (4 children) receiving caplacizumab from 22 UK hospitals. Patient characteristics and outcomes in the real-world clinical setting were compared with caplacizumab trial end points and historical outcomes in the precaplacizumab era. Eighty-four of 85 patients received steroid and rituximab alongside PEX; 26% required intubation. Median time to platelet count normalization (3 days), duration of PEX (7 days), and hospital stay (12 days) were comparable with RCT data. Median duration of PEX and time from PEX initiation to platelet count normalization were favorable compared with historical outcomes (P < .05). Thrombotic thrombocytopenic purpura (TTP) recurred in 5 of 85 patients; all had persistent ADAMTS13 activity < 5 IU/dL. Of 31 adverse events in 26 patients, 17 of 31 (55%) were bleeding episodes, and 5 of 31 (16%) were thrombotic events (2 unrelated to caplacizumab); mortality was 6% (5/85), with no deaths attributed to caplacizumab. In 4 of 5 deaths, caplacizumab was introduced >48 hours after PEX initiation (3-21 days). This real-world evidence represents the first and largest series of TTP patients, including pediatric patients, receiving caplacizumab outside of clinical trials. Representative of true clinical practice, the findings provide valuable information for clinicians treating TTP globally