James E. Sabin

A prospective analysis of autograft versus allograft in posterolateral lumbar fusion in the same patient. A minimum of 1-year follow-up in 144 patients.

Study Design One hundred forty four patients who underwent lumbar spine fusions had autografts placed on one side as a control and on the opposite side one of the following types of graft material was placed: iliac autograft, demineralized cancellous chips, demineralized cortical powder, demineralized cortical powder mixed with autograft, or mineralized cancellous chips. Alar anteroposterior and lateral postoperative radiographs were reviewed by three independent observers and graded for quality of fusion mass bilaterally. The follow-up was 14 to 27 months. Objectives This study evaluated the efficacy of various types of ethylene oxide-sterilized allograft bone used for spine fusions and compared them with autograft iliac bone in the same patient. Summary of Background Data Previous studies comparing autograft with allograft showed poorer fusion rates with allograft with posterior fusions. Most of the previous studies included smaller numbers of patients. No previous studies compared ethylene oxidetreated allograft with autograft. Results An analysis of the radiographs at a minimum of 1 year postoperatively revealed significantly lower values when allograft alone or in combination with autograft was used in comparison to autograft alone. Conclusions Ethylene oxide-treated allograft is inferior to autograft and should not be used for posterior lumbar fusions.

Accountability for reasonableness: an update

Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician (doi:10.1136/bmj.a1846), two ethicists, and four health economists (doi:10.1136/bmj.a1872) discuss how their ideas have developed—and been put into practice—since then

The second phase of priority settingGoodbye to the simple solutions: the second phase of priority setting in health careFairness as a problem of love and the heart: a clinician's perspective on priority settingIsrael's basic basket of health services: the importance of being explicitly implicit

What follows is the description of an improved hydraulic apparatus for the automatic adjustment of the inclination of the headlights of a motor vehicle, the adjustment being a dependent function of the axle load. The apparatus has a level sensor at each axle and each level sensor contains one metering piston and two positioning pistons. The rear axle level sensor is connected via two separate hydraulic lines to the front axle sensor, and the front axle sensor is in turn connected via two separate hydraulic lines to the positioning elements of the headlight housings. The internal construction of the two level sensors is substantially identical and is chosen such that the system is also suitable for manual adjustment.

Determining “Medical Necessity” in Mental Health Practice

Should mental health insurance cover only disorders found in DSM-IV, or should it be extended to treatment for ordinary shyness, unhappiness, and other responses to lifes hard knocks?

Ethical Guidelines for Physician Compensation Based on Capitation

There is a growing crisis of confidence in managed care. Because of its success in controlling costs to employers, managed care has triggered fears that necessary health services are being withheld...

Patients’ Beliefs and Preferences Regarding Doctors’ Medication Recommendations

BackgroundAn estimated 20–50% of patients do not take medications as recommended. Accepting a doctor’s recommendation is the first step in medication adherence, yet little is known about patients’ beliefs and preferences about how medications are prescribed.ObjectiveTo explore patients’ beliefs and preferences about medication prescribing to understand factors that might affect medication adherence.MethodsFifty members from 2 health plans in Massachusetts participated in in-depth telephone interviews. Participants listened to an audio-vignette of a doctor prescribing a medication to a patient and were asked a series of questions related to the vignette. Responses were reviewed in an iterative process to identify themes related to participants’ beliefs and preferences about medication prescribing.ResultsParticipants’ beliefs and preferences about medication prescribing encompassed 3 major areas: patient–doctor relationships, outside influences, and professional expertise. Important findings included participants’ concerns about the pharmaceutical industry’s influence on doctors’ prescribing practices and beliefs that there is a clear “best” medication for most health problems.ConclusionsPatients’ beliefs and preferences about medication prescribing may affect medication adherence. Additional empiric studies that explore whether doctors’ relationships with pharmaceutical representatives impact medication adherence by affecting trust are indicated. In addition, it would be worthwhile to explore whether discussions between patients and doctors regarding equipoise (no clear scientific evidence for 1 treatment choice over another) affect medication adherence.

Improving Fairness in Coverage Decisions: Performance Expectations for Quality Improvement

Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups.

Cluster randomized trials to study the comparative effectiveness of therapeutics: stakeholders' concerns and recommendations.

To describe the concerns raised by health plan members, providers and purchasers related to studying the comparative effectiveness of therapeutics using cluster randomized trials (CRTs) within health plans. An additional goal was to develop recommendations for increasing acceptability.

Physician-Rating Websites

Physician-rating websites can become a source of anxiety or an inducement to practice defensive medicine, but physicians should focus on collaborative patient relationships and responsible management of their online presence.

The small acoustic tumour; a chance to preserve hearing

SummaryThe authors report their experience in the surgical management of small (less than 1.5 cm diameter) acoustic neuromas. Twenty-nine patients were treated. They had suffered symptoms of unilateral eighth nerve dysfunction on average for 37 months. High resolution CT with iv contrast was the primary investigation. In equivocal cases, air meatography was performed. All operations were performed by the senior author (LS). All tumours were totally removed, there were no deaths and all patients had an excellent result. There were 6 complications (CSF leak 3; meningitis 2; deep venous thrombosis 1). The facial nerve was preserved in 26 cases (and functioned adequately in all) and. the cochlear nerve in 62%. In 4 cases with hearing pre-operatively, the decibel loss was the same or less post operatively. In 8 cases speech discrimination remained above 35%.