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The clinical utility of sentinel lymph node (SLN) surgery for staging the axilla after
neoadjuvant chemotherapy in node-positive breast cancer is unclear. In a clinical trial that
enrolled 663 women who presented with biopsy-proven node-positive breast cancer, received
neoadjuvant chemotherapy, and then underwent SLN surgery and axillary lymph node dissection, Boughey
and colleagues found that the false-negative rate of SLN surgery exceeded an acceptability threshold
of 10%. In an Editorial, Morrow and Dang discuss SLN surgery after neoadjuvant chemotherapy for
Current guidelines recommend that noncardiac surgery be delayed after coronary stent
placement—6 weeks’ delay for patients with bare metal stents and a year delay for those
with drug-eluting stents. In a retrospective cohort study of nearly 42 000 noncardiac surgical
procedures (28 029 patients) performed in the 2 years after stent placement, Hawn and colleagues
found that major adverse cardiac events were associated with emergency surgery and advanced cardiac
disease but not stent type or timing of surgery beyond 6 months after stent implantation. In an
Editorial, Brilakis and Banerjee discuss risks of perioperative stent thrombosis after stent
implantation and review considerations for patients who need surgery.
Oettle and colleagues previously reported that among 368 patients who had undergone complete,
curative-intent resection of pancreatic cancer between July 1998 and December 2004, 6 months’
adjuvant gemcitabine therapy compared with observation alone resulted in improved disease-free
survival. In this issue, the authors report that during follow-up through September 2012, patients
who had been randomly assigned to receive gemcitabine had increased overall survival as well.
In analyses of nationally representative data from more than 2800 hospitals and nearly 955 000
Medicare patient surgical discharges, Bilimoria and colleagues assessed whether the validity of
hospitals’ postoperative venous thromboembolism (VTE) rates—designated as a patient
safety indicator in quality improvement and public reporting initiatives—is influenced by
surveillance bias, wherein hospitals with higher VTE imaging rates identify more VTE events. The
authors found that hospitals with higher quality scores had higher VTE prophylaxis rates, but worse
risk-adjusted VTE rates, and that increased VTE rates were associated with increased VTE
imaging—suggesting that publicly reported VTE outcomes do not reflect hospital quality. In an
Editorial, Livingston discusses current quality measures for perioperative VTE prevention, public
reporting, and implications for patient safety.
Author Video Interview
A physically active, semiretired 85-year-old physician reported “extraordinary”
shortness of breath while walking up a steep hill. A transthoracic echocardiogram showed mild left
ventricular hypertrophy, a normal ejection fraction, and a peak gradient across the aortic valve of
97 mm Hg (normal, <15 mm Hg). In this JAMA Clinical Crossroads article, Manning reviews the
etiology, signs, and symptoms; patient assessment; and management of aortic stenosis.
Continuing Medical Education
A 58-year-old man with fever and night sweats, an elevated white blood cell count, anemia, and
mildly elevated troponin levels was admitted to the hospital. A transthoracic echocardiogram showed
mitral valve vegetations. After 4 days of systemic antibiotics, the patient’s leukocytosis and
anemia worsened. An abdominal computed tomography scan demonstrated air trapped within a gallstone.
His abdominal examination was unremarkable. What would you do next?
Highlights. JAMA. 2013;310(14):1423–1425. doi:10.1001/jama.2013.5351
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