ASA Advises No Longer Holding GLP-1 Agents Prior to Surgery for Most Patients

 Most patients should not stop taking GLP-1 receptor agonists prior to elective surgery, according to updated guidance

opens in a new tab or window from several medical societies, including the American Society of Anesthesiologists (ASA).

This recommendation, published in Surgery for Obesity and Related Diseases, is in stark contrast to 2023 guidanceopens in a new tab or window from the ASA, which originally advised a 1-week and 1-day hold of injectable and oral GLP-1 agents, respectively, prior to surgery. Because these popular weight-loss and diabetes drugs delay gastric emptying, the thinking was that a drug hiatus would reduce the risk of aspiration and regurgitation under anesthesia.

However, the new guidance -- signed off by the ASA, American Gastroenterological Association, American Society for Metabolic and Bariatric Surgery, International Society for Perioperative Care of Patients with Obesity, and the Society of American Gastrointestinal and Endoscopic Surgeons -- said this no longer applies to the majority of patients. Instead, most can continue their medication up until the day of surgery, but should follow a liquid diet for 24 hours before the procedure, depending on the specific circumstances.

"As anesthesiologists, we are committed to considering all factors to ensure patients get the best and safest care whenever anesthesia care is required," said ASA President Donald E. Arnold, MD, in a statement. "In many cases, patients with scheduled procedures should continue taking the drug. Scheduling of elective procedures should integrate awareness of circumstances when the risk of delayed stomach emptying is highest, such as when the patient is just beginning the drug and the dose is being increased, as well as for patients with significant GI [gastrointestinal] symptoms."

"Ideally, these risk factors should be assessed and minimized in advance, so the surgery or procedure can safely proceed," he added.

According to the guidance, care teams should consider the following factors when individually weighing a patient's metabolic need for the GLP agent with risks during the perioperative period:

• If patients are in the dose-escalation phase (associated with greater delayed gastric emptying) versus the maintenance phase
• Higher dose (e.g., 2.4 mg of semaglutide [Wegovy] vs 1 mg [Ozempic])
• Weekly dosing (which has more gastrointestinal side effects) versus daily dosing
• Presence of gastrointestinal side effects suggestive of delayed gastric emptying
• Medical conditions beyond GLP-1 usage that may also delay gastric emptying (e.g., bowel dysmotility, gastroparesis, Parkinson's disease)

"The assessment for these risk factors should occur with enough advance time prior to surgery to allow adjustments in preoperative care if indicated, including diet modification and evaluation of the feasibility of medication bridging if GLP-1 RA [receptor agonist] discontinuation is indicated," the guidance noted.

If there is still cause for concern the day of surgery, point-of-care gastric ultrasound could be used to assess aspiration risk. However, this technology "may be clinically limited based on institutional resources, interuser variability, and credentialing requirements," the guidance authors wrote.

These updates come on the heels of several recent studies looking into a GLP-1 hiatus prior to surgery that has divided anesthesiologistsopens in a new tab or window, with some research indicating a low aspiration riskopens in a new tab or window with GLP-1 use, and other studies suggesting the oppositeopens in a new tab or window.

Ultimately, the guidance emphasizes shared decision making between "the patient, the prescribing care team, the proceduralist or surgeon, and the anesthesiologist," noted guidance co-author Girish P. Joshi, MBBS, MD, vice chair of ASA's Committee on Practice Parameters, and colleagues in a corresponding letter to the editoropens in a new tab or window published in Anesthesiology. They advised that healthcare providers strike a balance between aspiration risk with the risks associated with stopping a GLP-1 receptor agonist, such as hyperglycemia, which could further complicate surgeries.

https://www.medpagetoday.com/surgery/anesthesiology/112653

Capital One warns of potential enforcement action over savings accounts

 A top federal agency may pursue enforcement action against Capital One over alleged misrepresentations related to its savings accounts, the consumer lender disclosed in a filing late on Thursday.

The company is responding to a letter the Consumer Financial Protection Bureau (CFPB) sent it earlier this month. The agency may also pursue litigation, Capital One warned.

At the center of the controversy is a lawsuit filed by some customers last year, who alleged that the company introduced a new "360 Performance Savings" account with a higher interest rate than it was paying to customers of another account, "360 Savings."

The customers claimed that this mismatch was not clearly communicated, resulting in them missing out on potential earnings.

Capital One said it had a contractual right to change interest rates at its discretion and information about the new account was always available on its website.

The company had filed a motion to dismiss the customers' lawsuit, a spokesperson told Reuters. CFPB declined to comment.

The probe comes as the company is awaiting regulatory approvals for its $35.3 billion acquisition of Discover Financial Services, which could reshape the payments industry.

Last week, New York Attorney General Letitia James said she was investigating if the deal violates the state's antitrust law. In July, Capital One said it will commit $265 billion over five years to lending, philanthropy and investment if its takeover goes through.

https://finance.yahoo.com/news/capital-one-warns-potential-cfpb-180306387.html

'Michigan city of Warren in focus amid worries about delayed election results'

 Officials in the U.S. battleground state of Michigan said they worry that the Democratic-leaning city of Warren could lag behind the rest of the state in reporting the results of Tuesday's presidential election, raising early doubts about the state's vote count.

Warren, unlike Detroit and most other cities in Michigan, opted not to take advantage of changes enacted in a 2022 state law allowing for up to eight days of preprocessing of absentee ballots. Instead, the city of 135,000 people will wait until Election Day to verify and tabulate more than 20,000 mail-in ballots.

The potential delay from Warren has worried some Democratic leaders that it could leave the results appearing artificially high for Republican Donald Trump on Tuesday evening, and that the former president would seek to exploit the situation by falsely declaring victory in the state before all votes were in.

"If the state is close at all and we don't have returns from Warren, which is our third-largest city, it's going to create all kinds of concerns," said Mark Brewer, an attorney and the former chair of the Michigan Democratic Party. "It's very, very worrisome."

The Trump campaign and the Republican National Committee did not directly address questions about Warren or Trump's plans to challenge the results. In a statement, Victoria LaCivita, the Trump campaign's Michigan spokesperson, criticized Democratic Vice President Kamala Harris' record and expressed confidence that Trump would defeat her in the state.

Opinion polls show a tight race between Harris and Trump in Michigan and other battleground states.

The decision not to preprocess absentee ballots was made by Warren City Clerk Sonja Buffa, a nonpartisan elected official. She said in a press release that she believed stretching out the process over several days was inefficient and raised the risk of information on the election being leaked.

State and local officials lobbied Buffa to opt for preprocessing, which was established as an option for clerks but not mandated by the new law. Buffa, who has more than two decades of experience overseeing elections, did not bend.

Last week Buffa asked the Warren City Council to approve $140,000 to purchase a fifth high-speed tabulator to help speed up ballot processing, a sign she wanted to deliver results quickly. She later rescinded that request and said she wanted to instead rent one for $40,000.

Buffa did not respond to requests for comment. Reuters could not establish whether she had been able to rent the tabulator or would have to make do with the four already in the city's possession.

As of Friday, 27,480 absentee ballots had been requested in Warren and 20,437 returned, according to the Michigan Secretary of State's website. In 2020 Democratic President Joe Biden beat Trump in Warren with about 55% of the vote.

In Michigan elections are administered by city and town clerks who report their results to the county. For Buffa, that means delivering the records from all her precincts via memory sticks to Anthony Forlini, Macomb County's clerk.

Forlini, who is a Republican, said in an interview that he was confident Buffa could process her absentee ballots in a timely manner, but was worried she would hold on to her memory sticks until the morning after Election Day, as she did during the August primary. Unlike the other clerks in Macomb, Buffa prefers to turn them in when all her election paperwork is finished, a process that takes hours, Forlini said.

Buffa has not told Forlini or Warren city council members that she will prioritize delivery of the sticks on Tuesday.

"We understand that she, the clerk, is not planning on releasing those sticks until she has all her paperwork done," said Warren City Council Secretary Mindy Moore, another nonpartisan elected official. "They could be waiting for us - the whole world."

Detroit, in contrast, started preprocessing its absentee ballots on Monday at a convention hall downtown. Each day hundreds of election workers have been working through about 11,000 ballots, with a goal of leaving only 10,000 mail-in ballots for the city to process on Election Day.

If all goes according to plan, Detroit hopes to avert the kind of delay that led to chaos in 2020, when Trump supporters descended on the convention hall and pounded on windows demanding that the absentee ballot counting be stopped.

Chris Thomas, a former Michigan elections director who is working as an adviser to Detroit's clerk, said he was worried about how quickly Warren could deliver its results.

"The track record of large jurisdictions counting large volumes of absentee ballots in a compressed, highly stressed environment is not good," Thomas said. "It's possible (Warren) will be one of the later, one of the last ones in."

https://www.yahoo.com/news/michigan-city-warren-focus-amid-101519229.html

How the Democrats Blew This Election

 John Barnes is one of my oldest friends in the world of conservative journalism. We were fellow interns (along with John Fund and the late Martin Morse Wooster) at Stan Evans’s National Journalism Center back in 1981, and he enjoyed a career in opinion journalism at both the Detroit News and N.Y. Post. He wrote the following note for his friends a few days ago, and I thought it was so good that I asked his permission to post it with us.

 

In 1862, with Union fortunes in the Civil War at a low ebb, Ohio Republican Sen. Ben Wade went to see Abraham Lincoln and urged him to fire Gen. George McClellan.

“And replace him with who, senator?” Lincoln asked.

“Anybody,” Wade replied.

“Anybody may be good enough for you, senator,” Lincoln said. “But I must have somebody.”

Which brings to mind the conundrum the Democrats face in this year’s election.

Back in 2020, with pandemic ongoing and the Summer of George, it seems a bare majority of the American people were ready to replace Donald Trump. But with whom? Bernie Sanders and Elizabeth Warren were clearly un-electable. Mayor Pete got gobs of undeserved publicity simply for being gay, but few thought the electorate was going to hand him the nuclear codes after only running (badly, BTW) the 199th largest city in America. Amy Klobuchar? (WHO?)

That left Joe Biden, the very definition of an old political warhorse, whose third bid for the brass ring was in the ditch, having finished way back in the pack in both Iowa and New Hampshire.

But who else was there? The Democratic kingmakers promptly cleared the field for him, effectively negating the ballots of tens of thousands of primary voters. Effectively, the Democrats were settling for “anybody” but Trump. And in the peculiar environment of that year, it was (barely) enough.

Unfortunately, the Democrats (and the nation) have discovered that when you settle for “anybody,” you get, well, ANYBODY.

Biden ran in 2020 promising basically three things: 1) He would “lock down the pandemic, not the country;” 2) he would get the economy back on track; and 3) he would unite the country after the “divisive” aberration of the Trump presidency.

On all three counts, he failed to deliver. Even after being handed what was marketed as a vaccine by the Trump administration, more Americans died of COVID on Biden’s watch than on Trump’s. The economic recovery has been as anemic as Obama’s was from 2008 — with the added “bonus” of the return of inflation after four decades. Finally, Biden’s hot temper and Ahab-like determination to destroy Donald Trump only drove the country’s divisions even deeper.

And none of this was to mention Biden’s increasingly obvious physical and mental disability that made his ego-driven bid for a second term look positively fantastical.

Realizing they had settled for “anybody” and gotten him, the Democratic kingmakers decided to re-run the 2020 playbook. Faced with an un-electable incumbent, they staged what amounted to a palace coup and forced him to remove himself from the race with only four months remaining to the election.

But Lincoln’s question loomed. Replace him with whom?

While it appears that Barack Obama and Nancy PelosiZ—the prime movers behind the coup—wanted some kind of “lightning primary” to choose a candidate (likely CA Gov. Gavin Newsom), Biden made their decision for them by endorsing his VP, Harris. Boxed in by their own racial and sexual ideology, the Democratic establishment had little choice but to go along.

But Harris was far from ideal. She was famously unpopular, having dropped out of the 2020 election campaign before the calendar had even turned to 2020. Biden didn’t want her as his running mate (he preferred MI Gov. Gretchen Whitmer), but he owed SC Rep. James Clyburn his nomination and the latter insisted on a “woman of color.” Harris was the only remotely plausible choice, so she got the nod.

As Veep, she lived down to expectations, making a series of gaffes and going through staff like matchsticks amid leaks about laziness and poor preparation.

Once again, the Democrats had settled for “anybody.” Unfortunately for them, it doesn’t appear “anybody” will be able to do the trick this time.

Whatever else you think of him, Donald Trump is undeniably “somebody.” He’s a man of numerous accomplishments. You can see, feel and touch the buildings he’s constructed and play on the golf courses he’s built. His personal life has been, er, UNCONVENTIONAL. But Bill Clinton blew conventional personal lives for presidents out of the water.

And like one of those funhouse clowns that keeps popping up smiling no matter how hard or how many times you punch him in the nose, Trump steadfastly refuses to go down and stay down. His opponents — not all of them Democrats, by any means — have thrown literally everything at him in an effort to remove him from the political stage. (Up to and including assassination.) None of it has worked, or seems likely to.

It’s an old saying: you can’t beat somebody with nobody, and Kamala Harris has spent the last four months revealing herself well and truly as nobody. Lincoln had it pinned down 162 years ago. “Anybody” might be good enough for a political party; but, most of the time, Americans seem to prefer a “somebody.”

https://www.powerlineblog.com/archives/2024/10/guest-column-how-the-democrats-blew-this-election.php

YouTube Pushes Back Against NY Times' Attempts To Censor Conservatives

 by Dmytro “Henry” Aleksandrov via Headline USA,

Despite its reputation as one of the most well-known Big Tech censors, YouTube surprised conservative Americans by pushing back against the New York Times’ claim that some right-wing political commentators were spreading “misinformation” right before the election.

The Times pressured YouTube to censor or outright deplatform political commentators like Tim Pool, Michael Knowles, Tucker Carlson, Ben Shapiro, Steve Deace and Rudy Giuliani, but the Big Tech platform refused.

“The ability to openly debate political ideas, even those that are controversial, is an important value — especially in the midst of election season,” she said in a statement to the newspaper.

After realizing that YouTube won’t censor those people, the Times made the Big Tech platform one of the villains in the story.

“Within months [after June 2023], the largest video platform became a home for election conspiracy theories, half-truths and lies. They, in turn, became a source of revenue for YouTube, which announced growing quarterly ad sales on Tuesday,” the newspaper wrote.

The Times also claimed that YouTube has “acted as a megaphone for conspiracy theories.”

“The commentators used false narratives about [2020 election] as a foundation for elaborate claims that the 2024 presidential contest was also rigged — all while YouTube made money from them,” the newspaper wrote.

Conservatives on Twitter criticized the Times for its attempts to silence those who oppose the mainstream media narrative.

“This article is effectively trying to strongarm YouTube into censoring voices that the New York Times disapproves of. Shameful behavior from a newspaper,” @TheRabbitHole84 wrote.

Conservative commentator Ian Miles Cheong also responded to the recent news.

“You really don’t hate the New York Times enough,” he wrote.

People from the free-speech platforms also used their chance to criticize the Times and promote their companies.

Notice how the New York Times is targeting @TuckerCarlson [and] @benshapiro on YouTube, even though those same creators are also on Rumble. Reason why? They know Rumble will them to [f***] off,” CEO of Rumble Chris Pavlovski wrote.

Twitter’s CEO Linda Yaccarino also responded to the recent article.

“We are not afraid of Media Matters. We are not afraid of The NY Times. And they shouldn’t be afraid of an informed group of citizens who are dedicated to preserving freedom of speech. Yet THEY seem to be?” she wrote.

Conservatives mentioned in the article also responded after discovering that the Times was working on the hit piece.

https://www.zerohedge.com/political/youtube-pushes-back-against-ny-times-attempts-censor-conservatives

Which Is A Bigger Disaster, Major Hurricanes Or The Politicization Of FEMA?

 Government Accountability Institute's Peter Schweizer and Eric Eggers discussed the politics of disaster relief and FEMA's shift from "utilitarian emergency management" to "disaster equity" in the wake of Hurricane Helene, on the Government Accountability Institute's "The Drill Down" podcast.

"We could play a bunch of clips like this. Kamala Harris says the FEMA response has been "tremendous," we have local media in North Carolina -- the Charlotte Observer, a liberal paper, says FEMA is doing a great job and there are fake rumors out there. The bottom line is you're hearing this on the ground from Cedar Key, Florida up to North Carolina, that there are major problems here," Schweizer said.

"FEMA has a certain number of disaster personnel, they are deployed around the country where there are crises. One of the crises in the Biden administration has been along the U.S.-Mexican border with this flood of illegal immigrants coming into the U.S."


"And we know that FEMA now has been spending large sums of money helping with migrants that show up at the border. In fact, there are FEMA personnel along the border, and the Biden administration has lied about this," he said.

Schweizer cited this video where White House spokesperson Karine Jean-Pierre has two different stories about the role of FEMA in processing illegal migrants.

"If you're a government agency, you can only do a couple of things really well," Schweizer said. "Mission creep is part of it, and why do they do that? Money! There's only so much we can spend on disaster relief, so FEMA says they're going to spend and get involved in a bunch of other things so they can increase the amount they get from the federal government every year."

Eggers comments: "Even though you hear some reporters disputing that Donald Trump said they spent all their money on the migrants, it is 100% true that FEMA's Emergency Food and Shelter Program has been reshaped to provide funding to 'families and individuals encountered by the DHS,' $685 million have been reallocated to illegal aliens. That's a clearly true thing. And by the way, we're running out of money to take care of victims of hurricanes. If you look at FEMA's disaster relief budget, they spent $4 billion on Covid-19 aid in September of this year, which is the most they've had in any month since "October 2023. So hurricanes are getting worse, but apparently, so is Covid -- four years after the pandemic."

"So if DHS Secretary Mayorkas is saying FEMA doesn't have the funds to make it through the season, maybe some of the funds that went to feed and fund migrant programs is now money that's not available for hurricane relief," Eggers said.

"It is money and personnel," Schweizer added. "You have programmatic expansion, they're doing immigration and all these other issues, but they're changing the definition in a way of 'disaster relief.' If you thought the wokeness affecting American corporations was bad enough, it's now affecting FEMA. When you see these volunteers going in and not getting paid, our federal government is focused on 'equity' when it comes to disaster relief."

Schweizer comments on a video of an internal FEMA meeting where they prioritize "disaster equity" over "utilitarian emergency management."

"They acknowledge that disaster relief has been up to this point, utilitarian. The greatest good for the greatest number. Hello! Isn't that what disaster assistance is supposed to be about? And she says, no, we're moving to a more advanced 'disaster equity' where we're now going to focus on certain individuals and communities," Schweizer said. "This is insane. This is absolutely insane."

"Their actual goal in disaster relief, she said, is no longer the greatest good for the greatest number of people!"

Eggers adds: "FEMA lists three goals on their website as their strategic plan, to address 'key challenges in emergency management.' You might think that means hurricanes, earthquakes, flooding. no, it turns out the number one goal is 'to instill equity as the number one goal of emergency management.' They also get into climate resilience and 'diversity., equity, and conclusion can not be optional' in FEMA's plan."

"What does 'disaster equity' look like?" asked Schweizer. "Do you have to have the equivalent portion of people die in each community? If you have a town where 15% of the population is Chinese-American, it is not equitable if too many or too few of that community dies?"

https://www.realclearpolitics.com/video/2024/10/30/peter_schweizer_which_is_a_bigger_disaster_major_hurricanes_or_the_politicization_of_fema.html

3 Reasons Harris Will Lose the Election

 There are three reasons why Kamala Harris will lose on Tuesday.

First, a historic Democratic voting bloc will desert her in margins the polls haven’t anticipated. Hundreds of thousands of traditional Democrats who came of age in postwar America can’t visualize Ms. Harris walking in the footsteps of their legendary party leaders who preceded her—icons like Franklin D. Roosevelt, Harry Truman, John F. Kennedy, Lyndon Johnson and Hubert Humphrey. She suffers from a stature gap that a billion dollars of advertising can’t change, and even if voters don’t mark their ballot for Donald Trump, it will be to his benefit.

The vice president had nearly four years to rise to levels of national and international prominence—to expand her vitae beyond being Joe Biden’s choice to fill a designated slot. She squandered that opportunity, or perhaps Mr. Biden and his inner circle didn’t loosen the leash. Either way the result is the same: She isn’t the person who matches the moment.

Second, Ms. Harris was unprepared to enter the rough and tumble of national politics and at the 11th hour relies on being propped up, as she has throughout her career, by patrons—Barack Obama, his operatives and a national media that is predominantly desperate to prevent Mr. Trump from re-entering office. Ms. Harris is a victim of her own success through moving up the political ladder without being fully tested by challenge and conflict.

Hence, while she promotes her career path as a tough prosecutor, when it came to time to face the national jury, she abdicated to the teleprompter and friendly interviewers. The canary in the coal mine for her impending defeat is the veiled betrayal by those who engineered the putsch that shoved Ms. Harris through the door while forcing Mr. Biden out. They ridicule the vice president’s odd-ball answers in televised interviews as retreats into “Word Salad City.”

Third, when she responded on “The View” that there wasn’t a thing that came to her mind that she would “have done differently than President Biden,” Ms. Harris confirmed the substance-free foundation of her cause by placing no distance between herself and the failures of her partner. Either she couldn’t find a way to escape her baked-in California Bay Area political culture, or she was flummoxed by her own slippery evasions from left-wing orthodoxy. Nevertheless, there is an empty hole where potential leaders of the free world must have a strong message. She has filled it with the bizarre notion that if she loses, Mr. Trump would establish fascism in America.

That makes for an unserious person seeking to navigate an uncertain world and fragile economy. Last-minute crazy charges and celebrity parades of Bruce Springsteen, Willie Nelson, Beyoncé and Michelle Obama merely reinforce the Potemkin village front of the unraveling Harris-Walz campaign.

Ms. Harris’s lack of stature, unreadiness for prime time, and content-confused narrative are why voters will opt for a former president with a proven record over an untested swimmer without a life vest.

Kenneth Khachigian was chief speechwriter to Ronald Reagan and an aide to Richard Nixon. He is author of the memoir “Behind Closed Doors: In the Room With Reagan and Nixon.”

https://www.wsj.com/opinion/the-three-reasons-harris-will-lose-presidential-election-unprepared-no-clear-message-db922adb