This Week in JAMA FREE

Patients with drug-resistant epilepsy are generally referred for surgery after years of seizures—often too late to avoid significant disability. To assess the effect of early surgical therapy on seizure control, Engel and colleagues randomly assigned 38 patients with mesial temporal lobe epilepsy—refractory to antiepileptic drug therapy for no more than 2 consecutive years—to receive anteromesial temporal lobe resection and continued antiepileptic drug treatment or continued drug treatment alone. The authors report that patients who underwent resective surgery had a lower risk of seizures during 2 years' follow-up. In an editorial, Schomer and Lewis discuss implications of the study findings for patients with refractory epilepsy.

5α-Reductase inhibitors such as dutasteride—used to treat benign prostatic hyperplasia and androgenic alopecia—block the conversion of testosterone to 5α-dihydrotestosterone (DHT) with unclear effects on androgen-dependent tissues. Bhasin and colleagues examined the effects in a clinical trial that involved 139 healthy men aged 18 to 50 years in whom endogenous testosterone production had been suppressed. The men received testosterone replacement and were randomly assigned to receive either dutasteride or placebo for 20 weeks. Among the authors' findings was that change in fat-free mass—the primary study outcome—did not differ among men receiving dutasteride or placebo, suggesting that the conversion of testosterone to DHT is not essential for mediating its anabolic effects on muscle. In an editorial, Gruntmanis discusses the role of 5α-reductase inhibition in men receiving testosterone replacement.

In a retrospective cohort of 141 029 Iraq and Afghanistan war veterans who received a non–cancer-related pain diagnosis within 1 year of entering the Veterans Affairs health care system, Seal and colleagues found that veterans with a mental health diagnosis—particularly posttraumatic stress disorder—were more likely to receive opioids for pain, had higher-risk opioid use patterns, and were at increased risk of opioid-associated adverse clinical outcomes than veterans without mental health diagnoses.

Article AND AUTHOR VIDEO INTERVIEW

Severe hepatic vascular malformations in hereditary hemorrhagic telangiectasia (HHT) can be associated with high-output cardiac failure. In a study that enrolled 25 patients with HHT, severe liver involvement, and a high cardiac index, Dupuis-Girod and colleagues found that administration of bevacizumab—a vascular endothelial growth factor inhibitor—was associated with a decrease in cardiac output and with reduced duration and number of episodes of epistaxis.

After moving from a small private practice to a large group-model practice, Dr A, an experienced primary care internist, was frustrated by the organization's quality improvement activities that focused on populations rather than on individuals. In this Clinical Crossroads article, Landon discusses the use of quality indicators in patient care, barriers to physician adoption of quality improvement measures, and creation of practice environments and payment systems that support high-quality delivery of care.

Opinions are divided whether statin therapy should be offered as primary prevention to women who have elevated cholesterol levels but who have not had a cardiovascular event.

Retreat from advanced care planning

Article AND AUTHOR AUDIO INTERVIEW

Revised approach to CPR status

Provocative principles for health care reform

“I want to be straightforward but not blunt. I want to be compassionate but remain professional.” From “The Before.”

Call for Papers

Authors are invited to submit manuscripts for an upcoming JAMA theme issue.

Join David S. Ludwig, MD, PhD, March 21, from 2 to 3 PM eastern time to discuss weight loss strategies for adolescents. To register, go to http://www.ihi.org/AuthorintheRoom.

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

How would you manage a 75-year-old woman in complete remission after stage IIIC epithelial ovarian cancer? Go to www.jama.com, read the case, and submit your response by April 1.

For your patients: Information about epilepsy surgery.