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In this trial, administering aspirin before surgery and during the early postsurgical period did not affect the rate of death or nonfatal MI but increased the risk of major bleeding. This was true in patients who had not been taking aspirin and in those on a long-term aspirin regimen. Myocardial infarction is the most common major vascular complication that occurs after noncardiac surgery. 1 – 3 Noncardiac surgery is associated with platelet activation, 4 and coronary-artery thrombus may be a mechanism of perioperative myocardial infarction. 5 , 6 Aspirin inhibits platelet aggregation, 7 and the perioperative administration of aspirin may prevent major vascular complications by inhibiting thrombus formation. 8 In a meta-analysis of data from large, randomized trials involving more than 110,000 patients who were not undergoing surgery, the use of aspirin was shown to prevent myocardial infarction and major vascular events. 9 High-dose aspirin has not been shown to be superior to low-dose aspirin in preventing . . .

In this trial, clonidine, an α2-adrenergic agonist, did not reduce the rate of death or MI among patients undergoing noncardiac surgery. Clonidine did increase the risk of perioperative hypotension, bradycardia, and nonfatal cardiac arrest. Myocardial infarction is the most common major vascular complication of surgery and is associated with substantial mortality. 1 During and after noncardiac surgery, there is marked activation of the sympathetic nervous system, which can lead to a mismatch between the supply of and demand for myocardial oxygen and to subsequent myocardial infarction. 2 – 4 We previously reported that perioperative administration of a high-dose, long-acting beta-blocker (initiated 2 to 4 hours before surgery and continued after surgery) reduced the risk of myocardial infarction but increased the risk of death, stroke, and clinically important hypotension. 5 Clonidine, an α 2 -adrenergic agonist, blunts central sympathetic . . .

Remote ischemic preconditioning is a simple therapy that may reduce cardiac and kidney injury. We undertook a randomized controlled trial to evaluate the effect of this therapy on markers of heart and kidney injury after cardiac surgery. Patients at high risk of death within 30 days after cardiac surgery were randomly assigned to undergo remote ischemic preconditioning or a sham procedure after induction of anesthesia. The preconditioning therapy was three 5-minute cycles of thigh ischemia, with 5 minutes of reperfusion between cycles. The sham procedure was identical except that ischemia was not induced. The primary outcome was peak creatine kinase–myocardial band (CK-MB) within 24 hours after surgery (expressed as multiples of the upper limit of normal, with log transformation). The secondary outcome was change in creatinine level within 4 days after surgery (expressed as log-transformed micromoles per litre). Patient-important outcomes were assessed up to 6 months after randomization. We randomly assigned 128 patients to remote ischemic preconditioning and 130 to the sham therapy. There were no significant differences in postoperative CK-MB (absolute mean difference 0.15, 95% confidence interval [CI] −0.07 to 0.36) or creatinine (absolute mean difference 0.06, 95% CI −0.10 to 0.23). Other outcomes did not differ significantly for remote ischemic preconditioning relative to the sham therapy: for myocardial infarction, relative risk (RR) 1.35 (95% CI 0.85 to 2.17); for acute kidney injury, RR 1.10 (95% CI 0.68 to 1.78); for stroke, RR 1.02 (95% CI 0.34 to 3.07); and for death, RR 1.47 (95% CI 0.65 to 3.31). Remote ischemic precnditioning did not reduce myocardial or kidney injury during cardiac surgery. This type of therapy is unlikely to substantially improve patient-important outcomes in cardiac surgery. Trial registration: ClinicalTrials.gov, no. NCT01071265.

Insulin binding to the plasma membrane insulin receptors is the first step in insulin control of a cell's metabolism. Many factors influence insulin binding to plasma membrane receptors. In healthy subjects, the level of physical activity and the level of physical fitness seem to be major contributors. To further clarify the role of exercise in insulin binding, we have investigated the effects of continuous and intermittent types of exercise in untrained and trained subjects on insulin binding, glucose uptake, and changes in circulating leucocyte fractions. We found that circulating monocytes form the predominant fraction of mononuclear cells that express surface insulin receptors in healthy subjects, whereas circulating T-lymphocytes displayed negligible binding (2%) of insulin receptor-specific antibodies. This confirmed our thesis that monocytes could serve as a model of insulin binding. Our results showed that insulin binding decreased after 20 and 60 min of continuous, sub-maximal exercise in aerobically fit male subjects. Similar declines were also observed after 20 min of intermittent exercise. This diminished insulin binding appeared to be due to a decrease in the affinity of insulin receptors rather than to a decline in the total number of insulin receptors. Insulin binding in untrained subjects was not altered initially by either continuous or intermittent types of exercise. Following ten weeks of aerobic training of the same subjects, insulin binding was decreased following both types of exercise. Glucose uptake by both basal non-stimulated and insulin-stimulated monocytes was unchanged in both the trained or untrained subjects. Our findings show that trained individuals exhibit lower insulin binding and no change in glucose uptake during physical activity, suggestive of a higher efficacy of insulin action in physically fit subjects. We also found that monocytes are the predominant circulating mononuclear cell fraction that binds insulin.

This is the first report describing combined spinal epidural anaesthesia for labour and unexpected Caesarean section in a patient with mitral and aortic stenosis and insufficiency. The patient was a 30-yr-old GIPO with a history of rheumatic fever. She had moderate stenosis and insufficiency of the mitral and aortic valves. Combined spinal epidural anaesthesia was used throughout labour and subsequent Caesarean section. The patient remained haemodynamically stable throughout the procedure. Carefully planned regional anaesthesia was safely used for labour and operative delivery in this parturient with mitral and aortic valvular disease.