New anti-diabetic agents for the treatment of non-alcoholic fatty liver disease: a systematic review and network meta-analysis of randomized controlled trials

ObjectivesThis network meta-analysis aims to compare the efficacy and safety of new anti-diabetic medications for the treatment of non-alcoholic fatty liver disease (NAFLD).Materials and methodsPubMed and Scopus were searched from inception to 27th March 2022 to identify all randomized controlled trials (RCTs) in NAFLD patients. Outcomes included reductions in intrahepatic steatosis (IHS) and liver enzyme levels. The efficacy and safety of DPP-4 inhibitors, GLP-1 agonists, SGLT-2 inhibitors, and other therapies were indirectly compared using a NMA approach. Unstandardized mean difference (USMD) with 95% confidence intervals (CI) were calculated.Results2,252 patients from 31 RCTs were included. “Add-on” GLP-1 agonists with standard of care (SoC) treatment showed significantly reduced IHS compared to SoC alone [USMD (95%CI) -3.93% (-6.54%, -1.33%)]. Surface under the cumulative ranking curve (SUCRA) identified GLP-1 receptor agonists with the highest probability to reduce IHS (SUCRA 88.5%), followed by DPP-4 inhibitors (SUCRA 69.6%) and pioglitazone (SUCRA 62.2%). “Add-on” GLP-1 receptor agonists were also the most effective treatment for reducing liver enzyme levels; AST [USMD of -5.04 (-8.46, -1.62)], ALT [USMD of -9.84 (-16.84, -2.85)] and GGT [USMD of -15.53 (-22.09, -8.97)] compared to SoC alone. However, GLP-1 agonists were most likely to be associated with an adverse event compared to other interventions.ConclusionGLP-1 agonists may represent the most promising anti-diabetic treatment to reduce hepatic steatosis and liver enzyme activity in T2DM and NAFLD patients. Nevertheless, longer-term studies are required to determine whether this delays progression of liver cirrhosis in patients with NAFLD and T2DM.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42021259336.1

Comparative cardiovascular benefits of individual SGLT2 inhibitors in type 2 diabetes and heart failure: a systematic review and network meta-analysis of randomized controlled trials

BackgroundIn patients with type 2 diabetes (T2D) and a history of heart failure (HF), sodium–glucose cotransporter-2 inhibitors (SGLT2is) have demonstrated cardiovascular (CV) benefits. However, the comparative efficacy of individual SGLT2is remains uncertain. This network meta-analysis (NMA) compared the efficacy and safety of five SGLT2is (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and sotagliflozin) on CV outcomes in these patients.Materials and methodsPubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to September 23, 2022, to identify all randomized controlled trials (RCTs) comparing SGLT2is to placebo in T2D patients with HF. The main outcomes included composite CV death/heart failure hospitalization (HFH), HFH, CV death, all-cause mortality, and adverse events. Pairwise and NMA approaches were applied.ResultsOur analysis included 11 RCTs with a total of 20,438 patients with T2D and HF. All SGLT2is significantly reduced HFH compared to standard of care (SoC) alone. “Add-on” SGLT2is, except ertugliflozin, significantly reduced composite CV death/HFH relative to SoC alone. Moreover, canagliflozin had lower composite CV death/HFH compared to dapagliflozin. Based on the surface under the cumulative ranking curve (SUCRA), the top-ranked SGLT2is for reducing HFH were canagliflozin (95.5%), sotagliflozin (66.0%), and empagliflozin (57.2%). Head-to-head comparisons found no significant differences between individual SGLT2is in reducing CV death. “Add-on” SGLT2is reduced all-cause mortality compared with SoC alone, although only dapagliflozin was statistically significant. No SGLT2is were significantly associated with serious adverse events. A sensitivity analysis focusing on HF-specific trials found that dapagliflozin, empagliflozin, and sotagliflozin significantly reduced composite CV death/HFH, consistent with the main analysis. However, no significant differences were identified from their head-to-head comparisons in the NMA. The SUCRA indicated that sotagliflozin had the highest probability of reducing composite CV death/HFH (97.6%), followed by empagliflozin (58.4%) and dapagliflozin (44.0%).ConclusionSGLT2is significantly reduce the composite CV death/HFH outcome. Among them, canagliflozin may be considered the preferred treatment for patients with diabetes and a history of heart failure, but it may also be associated with an increased risk of any adverse events compared to other SGLT2is. However, a sensitivity analysis focusing on HF-specific trials identified sotagliflozin as the most likely agent to reduce CV death/HFH, followed by empagliflozin and dapagliflozin.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42022353754

Posterior Horn of Medial Meniscal Peripheral Capsular Lesion: The Arthroscopic Repair Technique Working in the Posterior Compartment

A posterior horn of medial meniscal peripheral capsular is usually associated with the anterior cruciate ligament injury. The conventional repair technique with the camera in the anterolateral portal cannot precisely restore the slope capsular synovium to the original attachment point. We present the arthroscopic technique for improving the accuracy and quality of the repair by working in the posterior compartment. When the posterolateral portal is used as the viewing portal, the accuracy of repair is improved because we can assess the full extent of the lesion and lift the sagging peripheral tissue to the more central part

Optimizing pectoralis major tendon repair: a modified knotless suture anchor technique using high-strength suture and tape

Background: Rupture of the pectoralis major (PM) tendon is infrequent but has shown an increased incidence in athletes, particularly weightlifters during bench presses. Various techniques for repair exist, yet no established gold standard has been defined. Methods: We present a modified surgical technique utilizing knotless suture anchors for PM tendon repair. The technique involves bringing the tendon end superiorly and inferiorly to the decorticated bone surface, ensuring broader tendon-to-bone contact. Knotless anchors with a unique suture locking mechanism facilitate tension adjustment. Additionally, the repair's strength is reinforced by employing both surgical tape and high-strength suture. Results: The utilization of both surgical tape and high-strength suture in conjunction with knotless suture anchors provides a secure and stable construct. This approach minimizes the risk of failure, reduces the potential for neurovascular injury associated with bicortical drilling, preserves imaging quality due to the absence of metal artifacts, and helps avoid the risk of fracture associated with traditional methods. However, surgeons should be aware of a potential disadvantage of increased surgical costs compared to traditional techniques. Conclusion: Our modified technique offers multiple advantages, including increased tendon-to-bone contact, enhanced stability, reduced neurovascular risks, and avoidance of potential fractures. This makes it a valuable option for successful PM tendon repairs. Surgeons should consider its benefits and weigh them against the associated costs for optimal patient care

Morphological classification of acromial spur: correlation between Rockwood tilt view and arthroscopic finding

Purpose and hypothesis: Acromion spur is the extrinsic factor for impingement syndrome and rotator cuff tear. The Rockwood tilt view can be used to evaluate prominence of the anterior acromion, however no study has shown the correlation of findings between the Rockwood tilt view and the arthroscopic finding. Methods: We developed the arthroscopic classification of acromion spur as type 1 flat spur, type 2 bump spur, type 3 heel spur, type 4 keel spur, and type 5 irregular spur. Patients with rotator cuff syndrome who underwent arthroscopic surgery were recruited. Two observers were asked to classify the type of spur from arthroscopic findings and Rockwood tilt views separately in random pattern. The prevalence of supraspinatus tendon tear was also recorded as no tear, partial-thickness tear, and full-thickness tear. Results: The keel spur (33.9%) was the most common finding followed by the heel spur (27.8%). The correlation was high especially for the heel, the keel, and the irregular spur (75.47%, 74.03%, and 72.73%, respectively.) These three types of spurs have a high prevalence of full thickness of supraspinatus tendon tear. Conclusion: The Rockwood tilt view can be used to evaluate the morphology of an acromion spur, especially the at-risk spur that correlates highly with the full-thickness supraspinatus tendon tear. The arthroscopic classification will also be a useful tool to improve communication between the surgeon and the guide for appropriate treatment in a rotator cuff tear patient when encountering the heel, keel, and irregular spur

Arthroscopic Treatment of Popliteal Cyst: A Direct Posterior Portal by Inside-Out Technique for Intracystic Debridement

Popliteal cysts are characterized by enlargement of the gastrocnemius-semimembranosus bursa. The pathogenesis includes a valvular opening between the knee joint and the bursa, and associated intra-articular pathology may give rise to knee effusion. The mainstay of treatment is conservative. If popliteal cysts are symptomatic, analgesia, aspiration, and steroid injection therapy may be considered, but most recur rapidly. In the past, open excision was an option if they remained symptomatic, but the associated recurrence rate was high. One important reason was that the intra-articular pathology causing the knee effusion was not treated. We present an alternative minimally invasive arthroscopic treatment using dye (methylene blue) directly injected into the cyst, which will leak from the cyst into the joint, to identify the valvular opening. The thickened valve is opened using a basket forceps and then enlarged using a motorized shaver to disrupt the 1-way mechanism between the joint and bursa, as well as to establish an unobstructed freeway connection between them. We also present a safe technique to create a direct posterior portal. Intracystic debridement of the fibrous membrane, nodules, and septa through this portal will decrease the recurrence rate of the popliteal cyst

Morphological classification of acromial spur: correlation between Rockwood tilt view and arthroscopic finding

Purpose and hypothesis: Acromion spur is the extrinsic factor for impingement syndrome and rotator cuff tear. The Rockwood tilt view can be used to evaluate prominence of the anterior acromion, however no study has shown the correlation of findings between the Rockwood tilt view and the arthroscopic finding. Methods: We developed the arthroscopic classification of acromion spur as type 1 flat spur, type 2 bump spur, type 3 heel spur, type 4 keel spur, and type 5 irregular spur. Patients with rotator cuff syndrome who underwent arthroscopic surgery were recruited. Two observers were asked to classify the type of spur from arthroscopic findings and Rockwood tilt views separately in random pattern. The prevalence of supraspinatus tendon tear was also recorded as no tear, partial-thickness tear, and full-thickness tear. Results: The keel spur (33.9%) was the most common finding followed by the heel spur (27.8%). The correlation was high especially for the heel, the keel, and the irregular spur (75.47%, 74.03%, and 72.73%, respectively.) These three types of spurs have a high prevalence of full thickness of supraspinatus tendon tear. Conclusion: The Rockwood tilt view can be used to evaluate the morphology of an acromion spur, especially the at-risk spur that correlates highly with the full-thickness supraspinatus tendon tear. The arthroscopic classification will also be a useful tool to improve communication between the surgeon and the guide for appropriate treatment in a rotator cuff tear patient when encountering the heel, keel, and irregular spur

Comparative cardiovascular benefits of individual SGLT2 inhibitors in type 2 diabetes and heart failure: a systematic review and network meta-analysis of randomized controlled trials

Background: In patients with type 2 diabetes (T2D) and a history of heart failure (HF), sodium–glucose cotransporter-2 inhibitors (SGLT2is) have demonstrated cardiovascular (CV) benefits. However, the comparative efficacy of individual SGLT2is remains uncertain. This network meta-analysis (NMA) compared the efficacy and safety of five SGLT2is (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and sotagliflozin) on CV outcomes in these patients. Materials and methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to September 23, 2022, to identify all randomized controlled trials (RCTs) comparing SGLT2is to placebo in T2D patients with HF. The main outcomes included composite CV death/heart failure hospitalization (HFH), HFH, CV death, all-cause mortality, and adverse events. Pairwise and NMA approaches were applied. Results: Our analysis included 11 RCTs with a total of 20,438 patients with T2D and HF. All SGLT2is significantly reduced HFH compared to standard of care (SoC) alone. “Add-on” SGLT2is, except ertugliflozin, significantly reduced composite CV death/HFH relative to SoC alone. Moreover, canagliflozin had lower composite CV death/HFH compared to dapagliflozin. Based on the surface under the cumulative ranking curve (SUCRA), the top-ranked SGLT2is for reducing HFH were canagliflozin (95.5%), sotagliflozin (66.0%), and empagliflozin (57.2%). Head-to-head comparisons found no significant differences between individual SGLT2is in reducing CV death. “Add-on” SGLT2is reduced all-cause mortality compared with SoC alone, although only dapagliflozin was statistically significant. No SGLT2is were significantly associated with serious adverse events. A sensitivity analysis focusing on HF-specific trials found that dapagliflozin, empagliflozin, and sotagliflozin significantly reduced composite CV death/HFH, consistent with the main analysis. However, no significant differences were identified from their head-to-head comparisons in the NMA. The SUCRA indicated that sotagliflozin had the highest probability of reducing composite CV death/HFH (97.6%), followed by empagliflozin (58.4%) and dapagliflozin (44.0%). Conclusion: SGLT2is significantly reduce the composite CV death/HFH outcome. Among them, canagliflozin may be considered the preferred treatment for patients with diabetes and a history of heart failure, but it may also be associated with an increased risk of any adverse events compared to other SGLT2is. However, a sensitivity analysis focusing on HF-specific trials identified sotagliflozin as the most likely agent to reduce CV death/HFH, followed by empagliflozin and dapagliflozin. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022353754.</p

Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder arthroplasty for primary osteoarthritis: a prospective, randomized controlled trial

There is no current consensus on subscapularis mobilization during total shoulder arthroplasty. The purpose of this prospective, randomized controlled trial was to compare functional and radiographic outcomes of the more traditional subscapularis tenotomy (ST) versus lesser tuberosity osteotomy (LTO). This study enrolled 60 shoulders in 59 patients with primary osteoarthritis. Thirty shoulders were preoperatively randomized to each group. Preoperative and 6-week, 3-month, 6-month, and 1-year postoperative data were collected. Ultrasound was performed at 3 months to evaluate subscapularis healing in tenotomy subjects, whereas radiographs were used to evaluate osteotomy healing. Intraoperative data included operative time, tenotomy or osteotomy repair time, and osteotomy thickness. No significant differences in range of motion or clinical outcomes occurred at baseline or 1 year postoperatively between the 2 groups. The mean total case duration for ST was significantly less than that for LTO (129.3 minutes vs 152.7 minutes), along with a significantly shorter subscapularis repair time for ST (34.3 minutes vs 39.3 minutes, P = .024). At final follow-up, 27 of 29 LTO shoulders (93.1%) showed bone-to-bone healing on radiographs, whereas 26 of 30 ST shoulders (86.7%) had no full-thickness tear of the subscapularis on ultrasound at 3 months. Both techniques produced successful objective and subjective clinical outcomes. LTO heals more reliably than ST. Mean total case and subscapularis repair times were significantly greater for LTO than for ST