Dying in the Intensive Care Unit: A Candle Vigil Using Illustrations

With death and dying in intensive care units, there should be bereavement support for families. We propose placing an illustration of a candle on the door of an unresponsive dying patient, with additional illustrations of votive candles at the nurses’ station opposite to the door as a neutral way of identifying these rooms with patients who transitioned to comfort care or who have died. The candle illustrations encourage staff members to modify their words, silence themselves, and reflect. After a 1-year tryout in the neurointensive care unit with a strong positive experience for staff and families, it can be perceived as a symbol of tranquility

Spontaneous Intracraniai Hypotension Mimicking Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: An excruciating headache of instantaneous onset is known as a thunderclap headache. A subarachnoid hemorrhage is the prototypical cause, but other serious disorders may also present with a thunderclap headache, including cerebral venous sinus thrombosis, carotid artery dissection, and pituitary apoplexy. We report a group of patients with thunderclap headaches as the initial manifestation of spontaneous intracranial hypotension caused by a spinal cerebrospinal fluid leak. METHODS: Among 28 patients with spontaneous intracranial hypotension due to a documented spinal cerebrospinal fluid leak, four (14%) initially experienced an excruciating headaches of instantaneous onset. RESULTS: The mean age of the four patients (two men and two women) was 35 years (range, 24-t5 yr). Nuchal rigidity was present in the three patients who sought early medical attention, and they underwent emergency computed tomographic scanning, lumbar puncture, and cerebral angiography to rule out an aneurysmal subarachnoid hemorrhage. The delay between the onset of headache and diagnosis of intracranial hypotension ranged from 4 days to 5 weeks. A fourth patient did not seek medical attention until 1 month after the ictus. CONCLUSION: Spontaneous intracranial hypotension should be included in the differential diagnosis of thunderclap headache, even when meningismus is present

Improving uniformity in brain death determination policies over time

Objective: To demonstrate that progress has been made in unifying brain death determination guidelines in the last decade by directly comparing the policies of the US News and World Report's top 50 ranked neurologic institutions from 2006 and 2015. Methods: We solicited official hospital guidelines in 2015 from these top 50 institutions, generated summary statistics of their criteria as benchmarked against the American Academy of Neurology Practice Parameters (AANPP) and the comparison 2006 cohort in 5 key categories, and statistically compared the 2 cohorts' compliance with the AANPP. Results: From 2008 to 2015, hospital policies exhibited significant improvement (p = 0.005) in compliance with official guidelines, particularly with respect to criteria related to apnea testing (p = 0.009) and appropriate ancillary testing (p = 0.0006). However, variability remains in other portions of the policies, both those with specific recommendation from the AANPP (e.g., specifics for ancillary tests) and those without firm guidance (e.g., the level of involvement of neurologists, neurosurgeons, or physicians with education/training specific to brain death in the determination process). Conclusions: While the 2010 AANPP update seems to be concordant with progress in achieving greater uniformity in guidelines at the top 50 neurologic institutions, more needs to be done. Whether further interventions come as grassroots initiatives that leverage technological advances in promoting adoption of new guidelines or as top-down regulatory rulings to mandate speedier approval processes, this study shows that solely relying on voluntary updates to professional society guidelines is not enough

Cortisone in Popular Culture: Roueché, Ray, and Hench

In this article, the authors offer a new perspective on how the administration of Compound E (ie, cortisone) to a volunteer Mayo Clinic patient with rheumatoid arthritis and the patient’s subsequent miraculous improvement led not only to a major, successful clinical trial but also a Nobel Prize. The early and late side effects as an undesirable outcome of treatment of corticosteroids would soon follow. Corticosteroid side effects became known in popular culture, first through an indepth article in The New Yorker by medical journalist Berton Roueché, and later through a major fiction film, Bigger than Life, directed by Nicholas Ray. The film used cortisone as a plot device to “unmask” what the filmmaker perceived to be the lie of middle class prosperity in America of the 1950s. Bigger than Life is also a cinematic argument against the use of cortisone. Dr. Philip Hench was also connected to Bigger than Life, and the Ray-Hench connection is further explored based on newly found material. The discovery of “wonder drug” cortisone and its potential side effects—all carefully described in the Roueché article but exaggerated in Nicholas Ray’s film in the 1950s—show how medicine can be portrayed in popular culture