Background: Glucagon-like peptide 1 agonists differ in chemical structure, duration of action and in their effects on clinical outcomes. The cardiovascular effects of once-weekly albiglutide in type 2 diabetes are unknown. Methods: We randomly assigned patients with type 2 diabetes and cardiovascular disease to the addition of once-weekly subcutaneous injection of albiglutide (30 mg to 50 mg) or matching placebo to standard care. We hypothesized that albiglutide would be noninferior to placebo for the primary outcome of first occurrence of cardiovascular death, myocardial infarction, or stroke. If noninferiority was confirmed by an upper limit of the 95% confidence interval for the hazard ratio of less than 1.30, closed-testing for superiority was prespecified. Findings: Overall, 9463 participants were followed for a median of 1.6 years. The primary composite outcome occurred in 338 of 4731 patients (7.1%; 4.6 events per 100 person-years) in the albiglutide group and in 428 of 4732 patients (9.0%; 5.9 events per 100 person-years) in the placebo group (hazard ratio, 0.78; 95% confidence interval [CI ], 0.68 to 0.90), indicating that albiglutide, was superior to placebo (P<0.0001 for noninferiority, P=0.0006 for superiority). The incidence of acute pancreatitis (albiglutide 10 patients and placebo 7 patients), pancreatic cancer (6 and 5), medullary thyroid carcinoma (0 and 0), and other serious adverse events did not differ significantly between the two groups. Interpretation: In patients with type 2 diabetes and cardiovascular disease, albiglutide was superior to placebo with respect to major adverse cardiovascular events. (Funded by GlaxoSmithKline; Harmony Outcomes ClinicalTrials.gov number, NCT02465515.) noninferiority; P = 0.06 for superiority). There seems to be variation in the results of existing trials with GLP-1 receptor agonists, which if correct, might reflect drug structure or duration of action, patients studied, duration of follow-up or other factors.

Adrenal hemorrhage is the most common cause of adrenal mass in newborns. We present a case of a fullterm male, born by cesarean section due to acute fetal distress from a mother with severe coronavirus disease 2019 (COVID-19) infection. He was diagnosed with hypoxic-ischemic encephalopathy, multifactorial shock, and early neonatal sepsis. On the seventh day of hospitalization, hemoglobin dropped and thus blood transfusion was required, and abdominal ultrasound showed bilateral adrenal hemorrhage. He developed relative adrenal insufficiency without either hemodynamic instability or electrolyte imbalances. The use of parenteral corticosteroids was not required. Follow-up ultrasonography and adrenal axis laboratory examination revealed complete resolution of adrenal hemorrhage. Neonatal adrenal hemorrhage has a wide variety of clinical manifestations. Ultrasound is preferred for both initial screening and follow-up evaluation. Adrenal insufficiency occurs rarely in neonatal adrenal hemorrhage. Treatment is usually conservative. We emphasize the importance of a timely diagnosis and clinical follow-up of adrenal hemorrhage in neonates with fetal distress born from mothers with severe COVID-19.

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Introduction: Choledochal cyst (CC) is a rare disease in western countries that presents in adults and is considered a premalignant lesion. A series of unusual presentations and complex management and some very infrequent situations are presented. Methods: We performed a case review of CC cases operated at Guillermo Almenara Hospital, Lima, Peru from 2008 to 2017. Cases of complex management due to their rare presentation were included. Ten cases of CC are described. Results: Case #1: CC associated with hepatic hydatid cyst. Case #2: CC associated with intracystic fasciola hepatica. Case #3: CC associated with a medusa-shaped arterial malformation at the cyst. Case #4: Jaundice after laparoscopic cholecystectomy. Video was reviewed and it is noticed that cholecystectomy and a resection of a CC, mistaken for the infundibulum, was performed. Case #5 and #6: Very distal resections of CC a few millimeters from the ampulla. Case #7: Same as cases #5 and #6 but presented in pancreas divisum. Case #8: Previously treated CC with a cysto-duodenal anastomosis underwent resection of the cyst and Roux-en-Y anastomosis. Case #9: Previously CC case treated with cysto-jejunal Roux-en-Y anastomosis. A complete resection of the cyst was performed laparoscopically. Case #10: Previously resected CC presented with abnormal pancreas head. Pancreaticoduodenectomy is performed. Conclusion: Choledochal cysts can have complex presentations and surgical management should be tailored for each individual case.

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