Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter-or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.

Background: Parenteral nutrition (PN) is an essential feeding route for specific patient populations. Despite its utility, PN is invasive, costly, and associated with clinical complications. In most U.S. hospitals, PN is overprescribed. This study measured rates of inappropriate PN use in hospitalized adults, as determined by the 2002 American Society for Parenteral and Enteral Nutrition guidelines, at 4 tertiary care South Carolina hospitals (facilities A–D). Secondary aims were to identify indicators of inappropriate use and estimated preventable costs. Methods: Over a 3‐month period, trained registered dietitians at each site collected data retrospectively and prospectively to determine PN appropriateness and indicators of use in 278 randomly selected PN cases. Results: PN therapy was inappropriately prescribed in 32% of cases, resulting in approximately 552 days and $138,000 in preventable hospital costs. Thirteen percent of patients who were prescribed inappropriate PN were discharged on home PN. Mean duration of PN therapy was higher in inappropriate cases vs appropriate cases (6 ± 7 days [range, 1–78 days] vs 10 ± 10.6 days [range, 1–51 days]; P < .004). Facility B had lower rates of inappropriately prescribed PN (23%) compared with facilities A (33%), C (35%), and D (38%). Dietitians recommended against PN in >70% of all inappropriate cases at facilities A and D compared with <45% at facilities B and D (P < .001). Facility B employed more certified nutrition support dietitians (68% of staff) and was among the 2 hospitals using a nutrition support team (NST). Conclusion: This study was novel by comparing PN practices in statewide hospitals. Results indicate that NSTs and certified nutrition support clinicians can curtail preventable spending from inappropriate PN use. Future studies should identify barriers in implementing evidence‐based practice.

Study Design: Review of the best-validated measures of cervical spine alignment in the sagittal axis. Objective: Describe the C2-C7 Cobb Angle, C2-C7 sagittal vertical axis, chin-brow to vertical angle, T1 slope minus C2-C7 lordosis, C2 slope, and different types of cervical kyphosis. Methods: Search PubMed for recent technical literature on radiograph-based measurements of the cervical spine. Results: Despite the continuing use of measures developed many years ago such as the C2-C7 Cobb angle, there are new radiographic parameters being published and utilized in recent years, including the C2 slope. Further research is needed to compare older and newer measures for cross-validation. Utilizing these measures to determine the degree of correction intraoperatively and postoperatively will enable surgeons to optimize patient-level outcomes. Conclusion: Cervical spinal deformity can be a debilitating condition characterized by cervical spinal misalignment that affects the elderly more commonly than young populations. Many of these validated measures of cervical spinal alignment are useful in clinical settings due to their ease of implementation and correlations with various postoperative and health-related quality of life outcomes.

Study Design. Retrospective review of prospectively collected data. Objective. The objective of this study was to evaluate outcomes between patients receiving LMWH versus UH in a retrospective cohort of patients with spine trauma. Summary of Background Data. Although multiple clinical trials have been conducted, current guidelines do not have enough evidence to suggest low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) for venous thromboembolism (VTE) prophylaxis in spine trauma. Methods. Patients with spine trauma in the Trauma Quality Improvement Program datasets were identified. Those who died, were transferred within 72 hours, were deemed to have a fatal injury, were discharged within 24 hours, suffered from polytrauma, or were missing data for VTE prophylaxis were excluded. A propensity score was created using age, sex, severity of injury, time to prophylaxis, presence of a cord injury, and altered mental status or hypotension upon arrival, and inverse probability weighted logistic regression modeling was used to evaluate mortality, venous thromboembolic, return to operating room, and total complication rates. E values were used to calculate the likelihood of unmeasured confounders. Results. Those receiving UH (n = 7172) were more severely injured (P < 0.0001), with higher rates of spinal cord injury (32.26% vs. 25.32%, P < 0.0001) and surgical stabilization (29.52% vs. 22.94%, P < 0.0001) compared to those receiving LMWH (n = 20,341). Patients receiving LMWH had lower mortality (odds ratio [OR]: 0.47; 95% CI: 0.42–0.53; P < 0.001; E = 3.68), total complication (OR: 0.92; 95% CI: 0.88–0.95; P < 0.001; E = 1.39), and VTE event (OR: 0.80; 95% CI: 0.72–0.88; P < 0.001; E = 1.81) rates than patients receiving UH. There were no differences in rates of unplanned return to the operating room (OR: 1.01; 95% CI: 0.80–1.27; P = 0.93; E = 1.11). Conclusion. There is an association between lower mortality and receiving LMWH for VTE prophylaxis in patients with spine trauma. A large randomized clinical trial is necessary to confirm these findings. Level of Evidence: 3

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