Glucagon-Like Peptide 1 Receptor Agonists: A Medication for Obesity Management.

PURPOSE OF REVIEW: The burden of obesity worldwide is high and projected to rise. Obesity increases the risk of several cardiovascular diseases and cardiometabolic risk factors; hence, utilizing effective long-term therapies for obesity is of utmost importance. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as effective therapies that achieve substantial weight loss and improve cardiometabolic risk. The purpose of this review is to discuss the role of GLP-1RAs in obesity management. RECENT FINDINGS: Two subcutaneous GLP-1RAs, liraglutide and semaglutide, have been evaluated in several clinical trials for weight loss. Liraglutide achieves a mean weight loss of 4-7 kg, and more than 50% of treated individuals achieve 5% or more weight loss. Semaglutide has a greater impact on weight loss, with a mean weight loss of 9-16 kg, and more than 50% of treated individuals achieve 10-15% or more weight loss. These results led to regulatory approval of these agents for weight loss in individuals with obesity, regardless of diabetes status. In addition to weight loss, the benefits of GLP-1RAs extend to other risk factors, such as glycemic control and blood pressure. Gastrointestinal symptoms are the most frequently encountered adverse events with incidences between 5 and 30%. Finally, the cost remains one of the most critical challenges that limit GLP-1RAs use. GLP-1RAs have robust weight loss benefits and are expected to have a critical role in the management of obesity in the coming years. Upcoming studies will evaluate the durability of weight loss achieved with GLP-1RAs and the impact on cardiovascular outcomes.

Quality Improvement Initiative to Reduce Time from Regional Anesthesia Placement to Delivery for Cesarean Delivery.

OBJECTIVE: Our objective was to evaluate the impact of a quality improvement (QI) initiative on the regional anesthesia placement-to-infant delivery time during cesarean delivery (CD). STUDY DESIGN: We performed a quality improvement trial. Before June 18, 2018, the preoperative protocol was as follows: the anesthesiologist administered regional anesthesia in the operating room then the nurse placed the Foley's catheter, clipped pubic hair, precleaned the abdomen, and abdominal preparation. On June 18, 2018, the protocol changed and all the preoperative preparation (Foley's clip and preclean) were performed prior to the arrival in the operating room. The records of patients who underwent scheduled or nonemergency CD between May 1 and July 15, 2018, were reviewed. Our primary outcome was time between the placements of regional anesthesia to infant delivery at the time of CD. Bivariate and multivariable analyses were performed. RESULTS: A total of 194 patients were included, 124 before and 70 after the process change. The change in process leads to a significant reduction in anesthesia-to-delivery time, even after adjusting for number of prior CD and body mass index (BMI). Other times were also significantly impacted by the change. CONCLUSION: Our QI initiative significantly decreased the time from anesthesia placement to delivery of the fetus. Performing preoperative preparation activities, such as Foley's placement and shaving, after regional anesthesia for CD, increase the risk of fetal exposure to maternal hypotension. We evaluated the impact of a QI initiative on regional anesthesia placement to infant delivery time during CD.

An Update on the Diagnosis and Management of Acute Right Heart Failure.

Right ventricular (RV) dysfunction and resultant acute right heart failure (ARHF) is a rapidly growing field of interest, driven by increasing appreciation of its contribution to heart failure morbidity and mortality. Understanding of ARHF pathophysiology has advanced dramatically over recent years and can be broadly described as RV dysfunction related to acute changes in RV afterload, contractility, preload, or left ventricular dysfunction. There are several diagnostic clinical signs and symptoms as well as imaging and hemodynamic assessments that can provide insight into the degree of RV dysfunction. Medical management is tailored to the different causative pathologies, and in cases of severe or end-stage dysfunction, mechanical circulatory support can be utilized. In this review, we describe the pathophysiology of ARHF, how its diagnosis is established by clinical signs and symptoms and imaging findings, and provide an overview of treatment options, both medical and mechanical.