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In This Issue of JAMA
October 9, 2013


JAMA. 2013;310(14):1423-1425. doi:10.1001/jama.2013.5351


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 breast cancer.

Related Editorial

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.

Related Editorial

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.

Related Editorial

Author Video Interview

Clinical Review & Education

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?