This Week in JAMA FREE

Patients with atherosclerotic internal carotid artery occlusion and hemodynamic cerebral ischemia are at high risk for subsequent stroke when treated medically. In the multicenter Carotid Occlusion Surgery Study, Powers and colleagues assessed whether extracranial-intracranial (EC-IC) bypass surgery added to optimal medical therapy would reduce the risk of subsequent ipsilateral ischemic stroke in this patient population. The investigators randomly assigned 195 patients with recent symptomatic and arteriographically confirmed atherosclerotic internal carotid artery occlusion and hemodynamic cerebral ischemia to receive EC-IC bypass surgery plus medical therapy or medical therapy alone. The patients were followed up for 2 years. The investigators reported that compared with medical therapy alone, EC-IC bypass surgery plus medical therapy was not associated with a lower risk of recurrent ipsilateral ischemic stroke. In an editorial, Broderick and Meyers discuss acute care of patients with ischemic stroke.

In an analysis of data from 17 847 patients who had undergone coronary revascularization, Shah and colleagues examined how physician billing practices may influence the use of cardiac stress imaging within 30 days of the index visit following revascularization, when routine stress testing is not endorsed by professional guidelines. The authors found that physicians who billed for both technical (facility/equipment) and professional (interpretation) components of nuclear and echocardiographic stress imaging studies were more likely to order these studies after coronary revascularization than physicians who only billed for test interpretation or did not bill for either component. In an editorial, Hollenbeck and Nallamothu discuss financial incentives associated with in-office provision of ancillary services and implications for patient care and health care reform.

ArticleArticle (AUTHOR VIDEO INTERVIEW)

Some data suggest that clinical signs of autism are preceded by or emerge concurrently with a period of brain overgrowth. This overgrowth includes the prefrontal cortex, where abnormalities have been theorized to underlie some autistic symptoms. In an analysis of postmortem prefrontal brain tissue obtained from 7 male children with autism and 6 male children without neurological disorders (controls), Courchesne and colleagues found that children with autism had 67% more neurons in the prefrontal cortex and greater brain weight for age than control children. In an editorial, Lainhart and Lange discuss neuroanatomic features associated with autism.

ArticleArticle (AUTHOR AUDIO INTERVIEW)

van Beijnum and colleagues performed a systematic review and meta-analysis of data from 137 observational studies—involving 13 698 patients and 46 314 patient-years of follow-up—to assess patient outcomes following microsurgery, embolization, stereotactic radiosurgery, or combination procedures to treat brain arteriovenous malformations. Overall, the authors found that the case-fatality rate declined over time but that treatment was associated with considerable risks and incomplete efficacy. The authors reported outcomes specific to each procedure and associated with selected patient characteristics.

“It was only after Annie Wasserman died that I moved beyond awaiting placement and began to question who she was and what she had seen in her 85 years on this earth.” From “Annie.”

Ongoing cuts to local public health department resources and proposed cuts to new federal funding for public health are hindering the provision of some services by many departments.

Patient-Centered Outcomes Research Institute: addressing cost and value

Narrative vs evidence: and, not or

Linking insurance coverage with clinical trial participation

Dr Bauchner summarizes and comments on this week's issue. Go to http://jama.ama-assn.org/misc/audiocommentary.dtl

How would you manage an 86-year-old woman with upper gastrointestinal bleeding who is anticoagulated and receiving antiplatelet therapy? Go to www.jama.com to read the case. Submit your response by December 4 for possible online posting.

Join Steven Zweig, MD, MSPH, Wednesday, November 16, from 2 to 3 PM eastern time to discuss the physician's role in patients' nursing home care. To register, go to http://www.ihi.org/AuthorintheRoom.

Theme Issue on Cardiovascular Disease

For your patients: Information about chronic sinusitis.