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BRITISH MEDICAL JOURNALgeneral anatomy resembles pernicious anaemia, and there is a failure in varying degree to respond to specific antipernicious-anaemia therapy, the course being sometimes prolonged with the help of blood transfusions (Wilkinson and Israels, 1935, 1936).The following is the report of a patient with achrestic anaemia under the care of Dr. Stock.A housewife aged 26 complained of weakness, lack of energy, dyspnoea, palpitation, and increasing pallor. There were no gastro-intestinal symptoms, glossitis, or involvement of the central nervous system or peripheral nerves. No haemolysis was to be found. Gastric secretion contained normal amounts of hydrochloric acid. Sternal puncture on May 7, 1947, showed an active cellular marrow with 42.5% megaloblasts, while a few days later it contained 8% megaloblasts and 34% normoblasts and was still very active and cellular. A blood count on

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Background The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.