Abstract Objective: To determine the effects of “prolonged” antiplatelet therapy (that is, given for one month or more) on “vascular events” (non-fatal myocardial infarctions, non-fatal strokes, or vascular deaths) in various categories of patients. Design: Overviews of 145 randomised trials of “prolonged” antiplatelet therapy versus control and 29 randomised comparisons between such antiplatelet regimens. Setting: Randomised trials that could have been available by March 1990. Subjects: Trials of antiplatelet therapy versus control included about 70 000 “high risk” patients (that is, with some vascular disease or other condition implying an increased risk of occlusive vascular disease) and 30 000 “low risk” subjects from the general population. Direct comparisons of different antiplatelet regimens involved about 10 000 high risk patients. Results: In each of four main high risk categories of patients antiplatelet therapy was definitely protective. The percentages of patients suffering a vascular event among those allocated antiplatelet therapy versus appropriately adjusted control percentages (and mean scheduled treatment durations and net absolute benefits) were: (a) among about 20 000 patients with acute myocardial infarction, 10% antiplatelet therapy v 14% control (one month benefit about 40 vascular events avoided per 1000 patients treated (2P< 0.00001)); (b) among about 20 000 patients with a past history of myocardial infarction, 13% antiplatelet therapy v 17% control (two year benefit about 40/1000 (2P<0.00001)); (c) among about 10 000 patients with a past history of stroke or transient ischaemic attack, 18% antiplatelet therapy v 22% control (three year benefit about 40/1000 (2P<0.00001)); (d) among about 20 000 patients with some other relevant medical history (unstable angina, stable angina, vascular surgery, angioplasty, atrial fibrillation, valvular disease, peripheral vascular disease, etc), 9% v 14% in 4000 patients with unstable angina (six month benefit about 50/1000 (2P<0.00001)) and 6% v 8% in 16 000 other high risk patients (one year benefit about 20/1000 (2P<0.00001)). Reductions in vascular events were about one quarter in each of these four main categories and were separately statistically significant in middle age and old age, in men and women, in hypertensive and normotensive patients, and in diabetic and non: diabetic patients. Taking all high risk patients together showed reductions of about one third in non-fatal myocardial infarction, about one third in non-fatal stroke, and about one sixth in vascular death (each 2P<0.00001). There was no evidence that non-vascular deaths were increased, so in each of the four main high risk categories overall mortality was significantly reduced. The most widely tested antiplatelet regimen was “medium dose” (75-325 mg/day) aspirin. Doses throughout this range seemed similarly effective (although in an acute emergency it might be prudent to use an initial dose of 160-325 mg rather than about 75 mg). There was no appreciable evidence that either a higher aspirin dose or any other antiplatelet regimen was more effective than medium dose aspirin in preventing vascular events. The optimal duration of treatment for patients with a past history of myocardial infarction, stroke, or transient ischaemic attack could not be determined directly because most trials lasted only one, two, or three years (average about two years). Nevertheless, there was significant (2P<0.00001) further benefit between the end of year 1 and the end of year 3, suggesting that longer treatment might well be more effective. Among low risk recipients of “primary prevention” a significant reduction of one third in non: fatal myocardial infarction was, however, accompanied by a non-significant increase in stroke. Furthermore, the absolute reduction in vascular events was much smaller than for high risk patients despite a much longer treatment period (4.4% antiplatelet therapy v 4.8% control; five year benefit only about four per 1000 patients treated) and was not significant (2P=0.09). Conclusions: Among a much wider range of patients at high risk of occlusive vascular disease than is currently treated routinely, some years of antiplatelet therapy - with aspirin 75-325 mg/day or some other antiplatelet regimen (provided there are no contraindications) - offers worthwhile protection against myocardial infarction, stroke, and death. Significant benefit is evident not only among patients with unstable angina, suspected acute myocardial infarction, or a past history of myocardial infarction, stroke, or transient ischaemic attack, but also among many other categories of high risk patients (such as those having vascular procedures and those with stable angina or peripheral vascular disease). There is as yet, however, no clear evidence on the balance of risks and benefits of antiplatelet therapy in primary prevention among low risk subjects.

Collaborative overview of randomized trials of antiplatelet therapy .1. prevention of death, myocardial-infarction, and stroke by prolonged antiplatelet therapy in various categories of patients

Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,* Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation

/pdf/acc-aha-2005-practice-guidelines-for-the-management-of-4ltfid6e9i.pdf

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)

Recommended standards for reports dealing with lower extremity ischemia: Revised version

Anesthesiology. First of two parts.

Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial.

Effect of lidocaine on left ventricular function.

Technic of circulatory assistance

BACKGROUND
Nipple-sparing mastectomy is commonly performed for breast cancer treatment or prevention. We present one of the largest breast reconstruction series in the literature.


METHODS
A single institution retrospective review was conducted 2007-2019.


RESULTS
Our query identified 3,035 implant-based breast reconstructions after nipple-sparing mastectomy including 2043 direct-to-implant and 992 tissue expander-implant reconstructions. The overall major complication rate was 9.15% and nipple necrosis rate 1.20%. Therapeutic mastectomy was associated with higher overall complications and explantations compared to prophylactic mastectomy (p<0.01). Comparing unilateral and bilateral procedures, bilateral mastectomy had increased risk for complications (OR 1.46, C.I. 0.997-2.145, p=0.05). Tissue-expander reconstructions had higher rates of nipple necrosis (1.9% vs. 0.88%, p=0.015), infection (4.2% vs. 2.8%, p=0.04), and explantation (5.1% vs. 3.5%, p=0.04) compared to direct-to-implant reconstruction. When assessing plane of reconstruction, we found similar rates of complications between subpectoral dual plane and prepectoral reconstruction. There was no difference in complications between reconstruction with acellular dermal matrix or mesh compared to total or partial muscle coverage without ADM/mesh (OR 0.749, 95% C.I. 0.404-1.391, p=0.361). Multivariable regression analysis revealed preoperative radiotherapy (OR 2.465, 95% C.I. 1.579-3.848, p<0.001), smoking (2.53, 95% C.I. 1.581-4.054, p<0.001), and a periareolar incision (OR 3.657, 95% C.I. 2.276-5.875, p<0.001) to be the strongest predictors of complications and nipple necrosis (p<0.05).


CONCLUSIONS
Nipple-sparing mastectomy and immediate breast reconstruction has a low rate of complications. In this series, radiation, smoking, and incision choice predicted overall complications and nipple necrosis while direct-to-implant reconstruction and acellular dermal matrix or mesh did not increase risk.

A Decade of Nipple-Sparing Mastectomy: Lessons Learned in 3035 Immediate Implant-based Breast Reconstructions.

CONCLUSION: This study demonstrates that most ambulatory plastic surgery pediatric patients will have sufficient pain relief with only over the counter pain medications, without the need for narcotic prescriptions. This study also demonstrates that the type of surgery can be used as a guideline for who should receive a narcotic prescription postoperatively. Additionally, education on proper disposal of narcotic medications may be a simple and effective target to decrease opioid availability for abuse. In an era of opioid abuse and misuse, which has been propagated by clinician’s opioid prescription practices, this research deepens the physicians’ understanding of postoperative pain management in pediatric plastic surgery ambulatory patients and serves to guide future pain management and narcotic regimens.

William G. Austen

Papers

Effect of lidocaine on left ventricular function.

Technic of circulatory assistance

A Decade of Nipple-Sparing Mastectomy: Lessons Learned in 3035 Immediate Implant-based Breast Reconstructions.

Pain Drawings Can Predict Poor Surgical Outcomes in Migraine Surgery

Horizons in cardiovascular pulmonary research.