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Objective: Tranexamic acid (TXA) is an FDA-approved antifibrinolytic that is seeing increased popularity in spine surgery owing to its ability to reduce intraoperative blood loss (IOBL) and allogeneic transfusion requirements. The present study aimed to summarize the current literature on these formulations in the context of short-segment instrumented lumbar fusion including ≥ 1-level posterior lumbar interbody fusion (PLIF)., Methods: The PubMed, Cochrane, and Web of Science databases were queried for all full-text English studies evaluating the use of topical TXA (tTXA), systemic TXA (sTXA), or combined tTXA+sTXA in patients undergoing PLIF. The primary endpoints of interest were operative time, IOBL, and total blood loss (TBL); secondary endpoints included venous thromboembolic complication occurrence, and allogeneic and autologous transfusion requirements. Outcomes were compared using random effects. Comparisons were made between the following treatment groups: sTXA, tTXA, and sTXA+tTXA. Given that sTXA is arguably the standard of care in the literature (i.e., the most common route of administration that to this point has been studied the most), the authors compared sTXA versus tTXA and sTXA versus sTXA+tTXA. Study heterogeneity was assessed with the I2 test, and grouped analysis using the Hedge's g test was performed for measurement of effect size., Results: Forty-five articles were identified, of which 17 met the criteria for inclusion with an aggregate of 1008 patients. TXA regimens included sTXA only, tTXA only, and various combinations of sTXA and tTXA. There were no significant differences in operative time, TBL, or postoperative drainage between the sTXA and tTXA groups or between the sTXA and sTXA+tTXA groups., Conclusions: The present meta-analysis suggested clinical equipoise between isolated sTXA, isolated tTXA, and combinatorial tTXA+sTXA formulations as hemostatic adjuvants/neoadjuvants in short-segment fusion including ≥ 1-level PLIF. Given the theoretically lower venous thromboembolism risk associated with tTXA, additional investigations using large cohorts comparing these two formulations within the posterior fusion population are merited. Although TXA has been shown to be effective, there are insufficient data to support topical or systemic administration as superior within the open PLIF population.

Objective: We aimed to elucidate associations between geographic location, size, and ranking of medical schools that orthopaedic surgery residents graduate from and the residencies that they match both pre-COVID-19 and post-COVID-19 pandemic by examining the 2017 to 2022 orthopaedic surgery residency cohorts., Methods: Demographics were extracted using Doximity Residency Navigator platform, the 2021 US News and World Report, and program websites. Medical schools were classified as large if they had >613 medical students. Postgraduate year 1 (PGY-1) (2021 match) and PGY-2 (2022 match) residents were classified as the COVID-19 cohort. Location was categorized as Northeast, Midwest, South, and West. Chi-square tests, Cohen's H value, and descriptive statistics were used for analysis with statistical significance set at p <0.05., Results: Four thousand two hundred forty-three residents from 160 accredited US orthopaedic residency programs (78.4%) were included. Northeastern applicants were most likely to match in the same region (p <0.01), and southern applicants were most likely to match at their home program (p <0.001). Applicants affected by the COVID-19 pandemic did not differ from their predecessors with regards to matching to the same region (p = 0.637) or home program (p = 0.489). Applicants from public medical schools were more likely to match in the same region and at their home program (p <0.001), whereas those from private medical schools were more likely to match at top-ranked residencies (p <0.001). Students from both top 25- and top 50-ranked medical schools were more likely to match at their home program (p <0.01) and attend top 20-ranked residency programs (p <0.0001)., Conclusion: These results demonstrate significant associations between matched residencies and attended medical schools' geographic location, school type, and ranking. During the pandemic, geographic trends were overall unchanged, whereas residents from large or lower-ranked schools were more likely to match at home programs, and those from private or top-ranked schools were less likely to attend top residencies., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A584)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Clerkship grading is a core feature of evaluation for medical students' skills as physicians and is considered by most residency program directors to be an indicator of future performance and success. With the transition of the U.S. Medical Licensing Examination Step 1 score to pass/fail, there will likely be even greater reliance on clerkship grades, which raises several important issues that need to be urgently addressed. This article details the current landscape of clerkship grading and the systemic discrepancies in assessment and allocation of honors. The authors examine not only objectivity and fairness in clerkship grading but also the reliability of clerkship grading in predicting residency performance and the potential benefits and drawbacks to adoption of a pass/fail clinical clerkship grading system. In the promotion of a more fair and equitable residency selection process, there must be standardization of grading systems with consideration of explicit grading criteria, grading committees, and/or structured education of evaluators and assessors regarding implicit bias. In addition, greater adherence and enforcement of transparency in grade distributions in the Medical Student Performance Evaluation is needed. These changes have the potential to level the playing field, foster equitable comparisons, and ultimately add more fairness to the residency selection process., (Copyright © 2023 by the Association of American Medical Colleges.)

Objective: Anorexia nervosa and obesity are common appetite disorders, which may be life threatening if not treated and often coincide with psychiatric disorders. We sought to investigate whether deep brain stimulation (DBS) of specific regions within the brain could aid in the treatment of these disorders. This review aims to organize the literature regarding the feasibility of DBS via clinical outcomes and synthesize the data on patient demographics and electrode parameters for future optimization., Methods: PubMed, Scopus, and Web of Science databases were all queried on 7 June 2022 to identify studies reporting the effect of DBS in treatment of either anorexia nervosa or obesity. We included studies involving 1) DBS, 2) treatment of anorexia nervosa or obesity, and 3) body mass index (BMI) as the primary outcome variable. Case reports, retrospective cohort studies, and randomized controlled trials were all eligible for inclusion. Exclusion of articles was based on the following criteria: 1) meta-analyses or systematic reviews or 2) describes diseases other than only anorexia or obesity. Screening of the 999 articles returned by an initial search yielded 23 studies for inclusion and further data extraction. Qualitative assessment of included studies was subsequently conducted in accordance with Newcastle-Ottawa Scale criteria., Results: We included 23 articles (17 anorexia, 5 obesity) that met our inclusion and exclusion criteria, which included 8 case reports, 13 case series, and 1 case-control study. Our primary variables of interest were location of DBS, change in BMI after intervention, electrode parameters, and psychiatric comorbidities. A total of 131 patients were included and analyzed, 118 of those belonging in the anorexia cohort. For patients with anorexia, we found that the most common place for DBS was the subcallosal cingulate followed by the nucleus accumbens, resulting in an overall increase in BMI by 24.82% over the span of a mean 17.1 months. Psychiatric comorbidities (major depressive disorder, obsessive-compulsive disorder, and anxiety) were common in the anorexia cohort. For patients with obesity, DBS was most common in the lateral hypothalamus followed by the nucleus accumbens, resulting in a small decrease in BMI by 3.97% over a mean 17.2 months. Data were insufficient for this cohort to report on additional psychiatric comorbidities or calculate the duration from diagnosis to treatment., Conclusions: DBS seems to be a promising solution in addressing treatment-refractory anorexia, but additional prospective studies are still needed to confirm this same usefulness for the treatment of obesity. Primary limitations included the apparent lack of data on DBS for obesity as well as the dearth of cohort studies assessing efficacy of DBS compared with control treatments. Although these limitations could not be addressed in the current review, this study may incentivize future trials to assess DBS in patients with appetite disorders in a more controlled fashion., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To determine the effect of povidone-iodine (PVP-I) nasal sprays on nasopharyngeal (NP) viral load as assessed by cycle threshold (Ct) on quantitative polymerase chain reaction (qPCR) of SARS-CoV-2 in outpatients., Study Design: Three arm, triple blinded, randomized, placebo-controlled clinical trial., Methods: Participants were randomized within 5 days of testing positive for COVID-19 to receive nasal sprays containing placebo (0.9% saline), 0.5% PVP-I, or 2.0% PVP-I. NP swabs for qPCR analysis were taken at baseline, 1-hour post-PVP-I spray (two sprays/nostril), and 3 days post-PVP-I spray (20 sprays/nostril). Symptom and adverse event questionnaires were completed at baseline, day 3, and day 5. University of Pennsylvania Smell Identification Tests (UPSIT) were completed at baseline and day 30., Results: Mean Ct values increased over time in all groups, indicating declining viral loads, with no statistically significant difference noted in the rate of change between placebo and PVP-I groups. The 2.0% PVP-I group showed statistically significant improvement in all symptom categories; however, it also reported a high rate of nasal burning. Olfaction via UPSIT showed improvement by at least one category in all groups. There were no hospitalizations or mortalities within 30 days of study enrollment., Conclusions: Saline and low concentration PVP-I nasal sprays are well tolerated. Similar reductions in SARS-CoV-2 NP viral load were seen over time in all groups. All treatment groups showed improvement in olfaction over 30 days. These data suggest that dilute versions of PVP-I nasal spray are safe for topical use in the nasal cavity, but that PVP-I does not demonstrate virucidal activity in COVID-19 positive outpatients., Level of Evidence: 2 Laryngoscope, 132:2089-2095, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Spinal robotics for thoracolumbar procedures, predominantly employed for the insertion of pedicle screws, is currently an emerging topic in the literature. The use of robotics in instrumentation of the cervical spine has not been broadly explored. In this review, the authors aimed to coherently synthesize the existing literature of intraoperative robotic use in the cervical spine and explore considerations for future directions and developments in cervical spinal robotics., Methods: A literature search in the Web of Science, Scopus, and PubMed databases was performed for the purpose of retrieving all articles reporting on cervical spine surgery with the use of robotics. For the purposes of this study, randomized controlled trials, nonrandomized controlled trials, retrospective case series, and individual case reports were included. The Newcastle-Ottawa Scale was utilized to assess risk of bias of the studies included in the review. To present and synthesize results, data were extracted from the included articles and analyzed using the PyMARE library for effect-size meta-analysis., Results: On careful review, 6 articles published between 2016 and 2022 met the inclusion/exclusion criteria, including 1 randomized controlled trial, 1 nonrandomized controlled trial, 2 case series, and 2 case reports. These studies featured a total of 110 patients meeting the inclusion criteria (mean age 53.9 years, range 29-77 years; 64.5% males). A total of 482 cervical screws were placed with the use of a surgical robot, which yielded an average screw deviation of 0.95 mm. Cervical pedicle screws were the primary screw type used, at a rate of 78.6%. According to the Gertzbein-Robbins classification, 97.7% of screws in this review achieved a clinically acceptable grade. The average duration of surgery, blood loss, and postoperative length of stay were all decreased in minimally invasive robotic surgery relative to open procedures. Only 1 (0.9%) postoperative complication was reported, which was a surgical site infection, and the mean length of follow-up was 2.7 months. No mortality was reported., Conclusions: Robot-assisted cervical screw placement is associated with acceptable rates of clinical grading, operative time, blood loss, and postoperative complications-all of which are equal to or improved relative to the metrics seen in the conventional use of fluoroscopy or computer-assisted navigation for cervical screw placement.

To the Editor: We read with great interest the article by Huynh et al.regarding the association between tranexamic acid (TXA) and blood loss in patients undergoing surgical treatment for hip fracture (Huynh PAN, Miller M, Will R. Intravenous Tranexamic Acid Decreases Blood Transfusions and Blood Loss for Patients with Surgically Treated Hip Fractures. Geriatric Orthopedic Surg Rehabil. 2021). The authors illustrated, via retrospective chart review of 505 patients who were surgically treated for hip fractures, that patients administered TXA had statistically significant decreases in perioperative blood loss and reduced relative risk of transfusion. Huynh et al. reported no statistically significant increases in thromboembolic events in patients given TXA. Mechanistically, TXA is a synthetic anti-fibrinolytic that competitively inhibits the plasminogen activation pathway. By preventing activated plasmin from de-stabilizing the fibrin matrix, TXA promotes clot formation. Given the anti-fibrinolytic effects of TXA, concerns in the literature exist regarding its use being associated with increased risk for thromboembolic events. However, it is important to note the complication profile associated with TXA is minimal, as elucidated by Brown et al., specifically finding that no patients who were administered TXA perioperatively experienced a thromboembolic event (or at least, there were no reports of thromboembolism or any other adverse events). While administration of TXA may theoretically increase the risk for thrombosis, Brown et al. showed this does not seem to occur in spinal laminectomy and fusion with posterior instrumentation. Similarly, in a systematic review of the literature describing TXA use in intracranial tumor resection, this study revealed a statistically significant reduction in the need for intraoperative blood transfusion in patients administered TXA. Upon consideration of postoperative outcomes, no significant increase in complication rate was found. This evidence in the existing literature on TXA use in orthopedic, spinal, and cranial neurosurgery exemplifies the wide potential of TXA for reducing blood loss with minimal complications in surgical procedures, especially involving the craniospinal axis., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)