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Teo J, Tan SYY, Tay M, et al. First case of E anophelis outbreak in an intensive-care unit. Lancet 2013; 382: 855–56. Matyi SA, Hoyt PR, Hosoyama A, Yamazoe A, Fujita N, Gustafson JE. Draft genome sequences of Elizabethkingia meningoseptica. Genome Announc 2013; 1: 4. Tan SY, Chua SL, Liu Y, et al. Comparative genomic analysis of rapid evolution of an extreme-drug-resistant Acinetobacter baumannii clone. Genome Biol Evol 2013; 5: 807–18.

Mortality after hip replacement Linda Hunt and colleagues (Sept 28, p 1097)1 assessed 90-day mortality after total hip arthroplasty for osteoarthritis. There is no strong evidence indicating that mortality and morbidity after hip replacement remain higher than in the general population 90 days after surgery. A recent study2 suggested that the risk of myocardial infarction after hip replacement is high during the first 2 weeks after surgery and decreases after 6 weeks. Hunt and colleagues’ study 1 indicated that the use of chemical prophylaxis, posterior approach, and spinal anaesthesia reduce the mortality rate. Chemical prophylaxis includes a large variety of drugs— including warfarin and aspirin. The authors’ claim of a protective effect of chemical prophylaxis on mortality should be interpreted with caution; it is not a green light for aggressive postoperative prophylaxis for low-risk patients at the expense of increased risk of postoperative complications, particularly surgical-site infection.3,4 Less invasive surgical approaches, including direct anterior approach, are used by the new generation of surgeons in the USA, while older surgeons mainly use a posterior approach. In view of the sharp learning curve of minimally invasive approaches, an initial increase in the rate of complications can be expected which could explain the better www.thelancet.com Vol 382 December 21/28, 2013

outcomes of the posterior approach in Hunt and colleagues’ study.1 Despite growing evidence about the benefits of neuraxial anaesthesia for joint replacement, surprisingly it is used in only about 25% of operations in the USA.5 Shifting from general to neuraxial anaesthesia is among the few modalities that would make joint replacement safer in the near future. JP is a consultant for Zimmer, Smith and Nephew, Convatech, TissueGene, Ceramtec, 3M, PRN, Medtronic, and Pfizer, and has stock options with Hip Innovation Technology and CD Diagnostics. MRR declares that he has no conflicts of interest.

*Javad Parvizi, Mohammad R Rasouli [email protected] Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA (JP); and Rothman Institute of Orthopaedics, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran (MRR) 1

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Hunt LP, Ben-Shlomo Y, Clark EM, et al. 90-day mortality after 409 096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013; 382: 1097–104. Lalmohamed A, Vestergaard P, Klop C, et al. Timing of acute myocardial infarction in patients undergoing total hip or knee replacement: a nationwide cohort study. Arch Intern Med 2012; 172: 1229–35. Sachs RA, Smith JH, Kuney M, Paxton L. Does anticoagulation do more harm than good?: a comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty 2003; 18: 389–95. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res 2013; published online July 2. DOI:10.1007/ s11999-013-3135-z. Memtsoudis SG, Sun X, Chiu YL, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013; 118: 1046–58.

Morality in the NHS marketplace On Nov 5, 2013, the outgoing chief executive of the National Health Service (NHS) Sir David Nicholson announced that “privatisation and competition were not proving to be a success”.1 In the wake of the Health and Social Care Act, the role of the NHS has come under increasing moral scrutiny. Here, we

postulate that the health-care market is morally questionable on two counts. First, in its present form, the healthcare market might curtail individual liberty. The UK commissioning model currently resembles a wholesale market more closely than a retail market, with the need for a commissioning middleman. Moreover, each commissioner contracts with a fairly narrow range of providers, thereby limiting patient choice. Theoretically, providers might tender to obtain substantial market share and then exploit the inevitable wiggle room in contracts that cannot cover every eventuality. In accordance with the inverse care law, providers might prioritise patients according to lowest risk rather than greatest need. Ultimately, at the level of the patient– doctor relationship, trust might be distorted by perceived financial motives. Second, market theory is not necessarily applicable to health care and should not be exercised without a burden of proof. Although the marketplace is intended to enable more efficient resource allocation, evidence that the market brings efficiency savings in the health-care setting is poor.2 Here, productivity gains are limited by a reliance on human interaction.3 Similarly, the ability of public–private partnerships to generate economic value for healthcare commissioners has fallen. Changes in global banking regulations have led to restrictions in long-term lending, with the resulting liquidity deficit increasing interest rates on project finance to historically high levels.4 For the NHS to retain its moral credibility, it must remain patientcentric, considering patients as pivotal members of clinical teams— eg, through open access to patient records. The market focus should be exchanged for one of collaboration, in which commissioners, patient representatives, and providers seek to work together. In recognising that not every health-care need can be met, there is a need for rationing,

Mike Kemp/In Pictures/Corbis

Singapore Centre on Environmental Life Sciences Engineering (SCELSE) and School of Biological Sciences, Nanyang Technological University, Singapore 637551, Singapore (SY-YT, LY); and Department of Laboratory Medicine, Microbiology Unit, National University Hospital, Singapore, Singapore (JT)

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whereby benefits and burdens are fairly distributed. Hölldobler and Wilson’s illustration of the ant colony is fitting: just as ants cooperate within their own colony but compete with new colonies when they are introduced, so must individual health-care providers learn to cooperate within a wider setting of competition, without an inherent need for a hierarchy or a market.5 We declare that we have no conflicts of interest.

*Barnabas J Gilbert, Mahiben Maruthappu, Laurence Leaver, Muir Gray [email protected]; University of Oxford, Oxford OX2 6HG, UK (BJG, LL, MG); and Harvard University, Cambridge, MA, USA (MM) 1

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Davis J. What were you doing while the NHS was being destroyed? Nov 13, 2013. http:// www.theguardian.com/commentisfree/2013/ nov/13/nhs-being-destroyed-labour (accessed Nov 15, 2013). The Lancet. The NHS: free and caring or a market commodity? Lancet 2013; 382: 571. Sullivan R. The Cost Disease. Lancet Oncol 2013; 14: 295. Hellowell M. The role of public-private partnerships in health systems is getting stronger. Commonwealth Health Partnerships, 2012. Hölldobler B, Wilson EO. The ants. Cambridge, MA: Springer-Verlag, 1990.

See Online for appendix

An early warning and response system for Syria The conflict in Syria has continued for more than 2 years: many Syrians have fled to escape the fighting (more than 5 million people have been internally displaced and about 2 million refugees are in neighbouring countries),1 and the Syrian healthcare system has been badly affected by the crisis.2–4 With huge population movements, substantial decreases in vaccination coverage, and deterioration of water and sanitation systems, the risk of epidemic-prone diseases is high. Epidemics pose a threat to health not only within Syria, but also in neighbouring countries. Public health surveillance is crucial 2066

to avert epidemics in emergency situations.5 In September, 2012, with the support of WHO, the Syrian Ministry of Health established an Early Warning Alert and Response System (EWARS) to strengthen the national surveillance system, detect epidemic threats early, respond to and control outbreaks, and monitor epidemic-prone diseases. EWARS is a network of reporting sentinel sites that collect information on a weekly basis. EWARS includes an alert element that signals outbreak at early stages, and it also includes preparedness plans. EWARS is supported by a network of laboratories, a communication network (via mobile phones), and a training component. At the beginning (September, 2012), 104 health centres were designated as sentinel reporting sites for EWARS across 14 governorates in the country. To overcome the problems in centres located in the governorates particularly affected by the conflict, non-governmental organisations’ health facilities and private hospitals and clinics were recruited by WHO in those governorates. By November, 2013, there were 368 reporting sites. Nine diseases were judged to be of high burden and epidemic-prone. A weekly bulletin is produced by EWARS and posted on WHO country office and Ministry of Health websites. EWARS is established and functional. It has succeeded so far in mitigating the consequences of many outbreaks, responding to a nation-wide measles outbreak, a typhoid outbreak in Deir ALZour, and the present polio outbreak. We declare that we have no conflicts of interest.

*Ghada Muhjazi, Hyam Bashour, Nidal Abourshaid, Hani Lahham [email protected] WHO Surveillance of Communicable Diseases, Damascus, Syria (GM); Damascus University, Damascus, Syria (HB); and Ministry of Health Damascus, Syria (NA, HL) 1

The UN Refugee Agency. Syria regional refugee response. http://data.unhcr.org/syrianrefugees/ regional.php (accessed Dec 3, 2013).

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WHO. Health: Syrian Arab Republic 2013. http://www.who.int/hac/syria_ dashboard_6june2013_final_small_.pdf (accessed Dec 3, 2013). Garfield R. Health professionals in Syria. Lancet 2013; 382: 205–06. Médecins Sans Frontières. Syria two years on: the failure of international aid so far. http:// doctorswithoutborders.tumblr.com/ post/44944097430/syria-two-years-on-thefailure-of-international (accessed Dec 3, 2013). WHO. Outbreak surveillance and response in humanitarian emergencies: WHO guidelines for EWARN implementation. 2012. http:// whqlibdoc.who.int/hq/2012/who_hse_gar_ dce_2012_1_eng.pdf (accessed Dec 3, 2013).

Improving medical research in the Arab world Arab nations’ medical research output and broad impact are weak according to the 2013 Scimago Institutions Rankings report 1 (of the 2740 universities and research institutions worldwide, only 60 were from Arab countries), which echoes the Scimago Journal and Country Rank (1996–2012), 2 and the 2013 Shanghai Ranking (appendix).3 Arab institutions were linked with 76 417 reports published between 1996 and 2012, which is only 4% of medical research reports by US-based institutions (table). Medical research publication from institutions from all Arab countries is almost half of that from Turkey, almost the same as that from Israel, and double that from Iran, but with a lower H index4 average (table). Promotion of medical research in Arab countries needs serious efforts and several strategic goals must be agreed on by all stakeholders— scientists and decision makers. The strategy should include upgrading research infrastructure and equipment, providing sufficient funds and high-quality training, as well as promoting excellence. Additionally, Arab scientists working abroad should be seen as an asset. China has already shown the way by recruiting qualified www.thelancet.com Vol 382 December 21/28, 2013

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