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Byline: E. Facco (1), P. Zucchetta (2), M. Munari (1), F. Baratto (1), A. U. Behr (1), M. Gregianin (2), A. Gerunda (1), F. Bui (2), M. Saladini (3), G. Giron (1) Keywords: Key words Brain death; SPECT; Cerebrovascular circulation; Brain injuries; EEG Abstract: Objective: To evaluate the effectiveness of single proton emission tomography (SPECT) with 99m.sup.Tc-HMPAO in the diagnosis of brain death (BD). Design: Prospective study in comatose and brain-dead patients. Setting: Neurologic ICU. Patients and methods: Fifty comatose patients (age range: 10 days--75 years) were submitted to SPECT study. In 21 of them (42 %) reversible factors (e. g., influence of drugs affecting the central nervous system) were present. Thirty-eight patients were clinically brain-dead, while the remaining 12 were tested both in pre-terminal conditions and after the clinical onset of BD. Interventions: Brain SPECT following i. v. injection of 99m.sup.Tc-HMPAO (300--1100 MBq), using a 4-headed gamma-camera (20 min, 360 deg, 88 images). Measurements and results: All patients tested in pre-terminal conditions showed preserved brain perfusion. Two of them had flat EEGs despite the absence of any reversible cause of coma three patients survived, but remained in persistent vegetative states. SPECT confirmed the diagnosis of BD in 45 out of 47 patients (95.7 %), clearly showing the arrest of brain perfusion (picture of 'empty skull') in two clinically brain-dead children (aged 10 days and 12 months, respectively) weak perfusion of the basal ganglia, thalamus and/or brain stem was still present, precluding the diagnosis of BD both of them died a few days later. Conclusions: Our results confirm the reliability of SPECT in the diagnosis of BD. A problem arises about its effectiveness in brain-dead children, but this seems to be a matter of definition of BD and cerebral viability, rather than a limit of SPECT. Author Affiliation: (1) Lab. Neurophysiology -- Neuro ICU, Dept. of Anesthesiology and Intensive Care, University of Padua, via C. Battisti 267, I-35121 Padova, Italy Tel.: +39.49.8 21 30 90, or +39.336.42 06 04 Fax: +39.49.8 75 42 56 email: efacco@uxl.unipd.it, IT (2) Nuclear Medicine Service I, University of Padua, via C. Battisti 267, I-35121 Padova, Italy, IT (3) Dept. of Neurology, University of Padua, via C. Battisti 267, I-35121 Padova, Italy, IT Article note: Received: 6 October 1997 Accepted: 21 July 1998

Dental anxiety (DA) can be considered as a universal phenomenon with a high prevalence worldwide; DA and pain are also the main causes for emergencies in the dental setting, so their prevention is an essential part of patient safety and overall quality of care. DA and its consequences are closely related to the fight-or-flight reaction and it seems reasonable to argue that the odyssey of DA began way back in the distant past, and has since probably evolved in parallel with the development of fight-or-flight reactions, implicit memory and knowledge, and ultimately consciousness. Basic emotions are related to survival functions in an inseparable psychosomatic unity that enable an immediate response to critical situations rather than generating knowledge, which is why many anxious patients are unaware of the cause of their anxiety. [ABSTRACT FROM AUTHOR]

Aim The aim was to compare the efficacy of Kenneth Reed and Gow-Gates inferior alveolar nerve blocks when performed by an inexperienced operator. Methods A group of 60 patients was randomised into two groups. One group had the Kenneth Reed technique used to administer an inferior alveolar nerve block whilst the other received the Gow-Gates technique. The efficacy of nerve block produced was evaluated both clinically and by electric pulp tester. MRI examination was undertaken to determine the spread of local anaesthetic. Results There were no significant differences in success rate of anaesthesia between groups. The failure rate for the Gow-Gates technique was 16.6%, whilst the failure rate for the Kenneth Reed technique was 23.3%. Time to onset was less with the Kenneth Reed technique. MRI examination showed the solution was more widely distributed after the Kenneth Reed block had been used. Conclusions Our research has demonstrated that the Kenneth Reed technique is equally effective at producing anaesthesia of the inferior alveolar nerve. Compared with conventional techniques there is a lower incidence of positive aspiration and potential for lower morbidity as the local anaesthetic is deposited further from the neurovascular bundle than when deposited near the mandibular foramen as in most conventional Inferior Alveolar Nerve Block techniques. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The assessment of the level of anesthesia is a very hard task, since no gold standard has stood out in the past three decades. Middle Latency Auditory Evoked Potential (MLAEP) is one of the most popular neurophysiological tools for anesthesia monitoring. Recently, Spectral Entropy (SpEn) has been introduced: it provides two different parameters, State Entropy (SE) and Response Entropy (RE). The aim of this prospective study is to check SpEn end-point, comparing it to MLAEPs in neurosurgical anesthesia. Methods: Twenty patients submitted to elective supratentorial neurosurgery for removal of a temporal–parietal meningioma were included in the study. SpEn and MLAEPs were simultaneously monitored using the M-entropy module S/5™ (GE Health Care, Helsinki, Finland) and Alaris Medical System AEP-ARX index monitor™ (AAI) (Kidemosevej, Denmark), respectively. Results: Four thousand and sixty four data points of SE, RE and AAI were recorded and ROC curves comparing AAI to RE and SE showed a highly significant (p <0.0001) area under the curve. The RE and SE cut-off values (showing maximal sensitivity with maximal specificity) to discriminate anesthesia from awake or consciousness sedation were 61 and 58, respectively. However, in a group of data points, low AAI was associated to high SpEn (577 data points for RE and 770 for SE) and vice versa (31 data points for RE and 43 for SE). The prediction probability for SE was 0.977 and for RE was 0.968. Conclusions: Our results suggest that SpEn is as effective as AAI. Significance: Our results show that SpEn is able to discriminate between the levels of wakefulness and surgical anesthesia. However, the meaning of data showing a discrepancy between AAI and SpEn is not yet clear and calls for further study. [Copyright &y& Elsevier]

The diagnosis of brain death (BD) still remains an intriguing problem and a matter of philosophical and methodological debate. The two most widely accepted concepts of BD are: (1) the whole-brain formulation, requiring the death of the entire encephalon, and (2) brainstem death, requiring the death of the brainstem only, regardless of higher brain viability. The electroencephalogram (EEG), introduced in 1968 by the Harvard Criteria, was the first ancillary test for the confirmation of brain death (BD), but its limitations (low sensitivity and specificity) have been widely emphasized during the past three decades. In general, the criteria for the diagnosis of brain death (BD) spring from the adopted concept of death, and closely depend upon it, giving rise to differences and even discrepancies in the diagnostic criteria adopted by different countries. In this regard, EEG can be relevant only when the death of the cortex is included in the definition of BD, whereas the kernel of the diagnosis remains the death of the brainstem in all cases, whatever the concept of BD. Auditory brainstem responses (ABRs) and short latency somatosensory evoked potentials (SEPs) are extensions of the clinical examination, allowing exploration of the brainstem and hemispheric structures that cannot be clinically explored in coma. Furthermore, they retain all their value even in patients with reversible characteristics of coma. When properly recorded and analysed, ABRs and SEPs allow a reliable confirmation of BD in most, if not all, cases and seldom detect residual life in the brainstem even in patients with a clinical and EEG picture of BD (despite the absence of any reversible cause of coma). They allow for the objective confirmation of brainstem death, and may improve the certainty of the diagnosis, so they should be included in brain death criteria. It is no longer acceptable to recommend EEG and not even mention evoked potentials. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the rCBF (133Xe clearance method) in migrainous patients free from attack. Fifty patients suffering from migraine without aura (group M) and 20 suffering from migraine with aura (group MA) (age range 20-50 years) were submitted to 32 channel rCBF mapping during the interictal period. The rCBF data of patients were compared with those obtained from 60 healthy control subjects (group C) and 21 patients suffering from tension-type headache (group TH). The mean (average of all channels) rCBF values were: group M = 70.5 +/- 13.7 ml/100g/min; group MA = 56.6 +/- 11.4 ml/100g/min; group C = 62.3 +/- 8.3 ml/100g/min; group TH = 62.1 +/- 8.4 ml/100g/min (F = 11.93; p < 0.001). As expected, patients belonging to group TH had a normal rCBF. The mean rCBF of group M was significantly higher than that of groups C and TH, while in group MA it was significantly lower than in groups C and TH. Group M showed a diffuse hyperemia, while group MA showed rCBF values significantly lower than normal in posterior regions, according to aura. Our results suggest that: (a) the rCBF pattern in migrainous patients is different from that in both controls and TH patients, even during the interictal period; (b) patients suffering from migraine with and without aura are two distinct subpopulations with opposite rCBF deviations. [ABSTRACT FROM AUTHOR]

Cardiac arrhythmias are not uncommon in dental practice, depending on many factors, including patient features, dental treatment and drugs administered. We describe a case of isolated atrial fibrillation (IAF) developed, in a young patient, soon after a supraperiosteal injection. The patient was admitted to hospital and recovered spontaneously. Since stress is a possible cause of IAF, this may has been triggered by endogenous and/or exogenous epinephrine. We highlight the need for careful preoperative evaluation, including anxiety assessment and treatment in all dental patients. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate whether the auditory brain stem responses (ABR) and short latency somatosensory potentials (SEP) from median nerve stimulation are effective tools in the confirmation of brain death. Thirty six brain dead patients were submitted to ABR and 24 to SEP in the same session. All waves of the ABR were absent in 28 (77.8 per cent) patients, while only wave I was present in the others (22.2 per cent). In SEP recordings the components later than P13 were absent in 17 (70.8 per cent) of cases; in the remaining seven patients (29.2 per cent) a N13/P13 dissociation (namely, retention of the cervical N13 and absence of the far-field P13) was found. The results suggest that SEP and ABR are reliable tools in the diagnosis of brain death and should be included in the criteria: they enable the functional status of two pathways in the brainstem to be checked, which cannot be explored by the clinical examination. [ABSTRACT FROM AUTHOR]

Several letters to the editor are presented in response to articles in previous issues including "Retrospective audit of the efficacy and safety of the combined intranasal/ intravenous midazolam sedation technique for the dental treatment of adults with learning disability," by M. C. G. Manley, N. J. Ransford, D. A. Lewis, S. A. Thompson, and M. Forbes in the 2008 issue and " Pre-operative fasting for intravenous conscious sedation used in dental treatment: are conclusions based on relative risk management or evidence?," by G. McKenna and S. Manton in the 2008.

This article presents the third molar removal in a highly hypnotizable patient, who had been successfully submitted to oral surgery with hypnosis as stand-alone anesthesia in previous sessions. Unexpectedly, hypnosis initially failed, as a result of a nocebo response due to a previous dentist's bad communication; two complaints made by the patient were associated with increased sympathetic activity (as defined by increased heart rate and electrodermal activity and decreased heart rate variability). After deepening of hypnosis, the patient achieved a full hypnotic analgesia allowing for a successful conclusion of the intervention, an event associated with decreased heart rate, electrodermal activity, and increased heart rate variability. Hence, the initial failure was paralleled by a decreased parasympathetic activity and increased sympathetic activity, while hypnotic analgesia was associated with the opposite pattern. The patient's postoperative report indicated that the initial failure of hypnosis depended on a strong nocebo effect because of a previous dentist distrusting hypnosis and persuading her that it was not enough to face a third molar removal.

The history of hypnosis has been marked by its effectiveness paralleled by prejudicial refusal, due to its ostensible incompatibility with the ruling Weltbild (picture of the world). Its interpretation has been mainly based on concepts like suggestibility, dissociation, hallucination, impairment of sense of agency, and free will. Nevertheless, little evidence and agreement has been reached so far on the nature of hypnosis and hypnotic ability, an uncertainty enhanced by the wide range of meanings and ambiguities of the used terms. This article analyzes the main epistemological implications involved in the topic.

Despite the huge development of pain management in the past decades, pain remains elusive and many patients still remain in the middle of the ford struggling between low drug efficacy and their overuse. A reason for pain elusiveness is its nature of subjective phenomenon, escaping the meshes of the objectivist, mechanist-reductionist net prevailing in medicine. Actually, pain is not only a symptom but an essential aspect of life, consciousness and contact with the world and its noetic and autonoetic components play a key role in the development of the concepts of pleasure-unpleasure and good-evil. The intensity and tolerability of pain and suffering also depend on what the pain means to the patient. The outstanding effects of placebo and nocebo, behavioral and non-pharmacological techniques warrant the need for a shift from the traditional positivist idea of patient as passive carrier of disease to the patient as active player of recovery and move toward a patient's centered approach exploiting individual resources for recovery. Among the mentioned techniques, hypnosis has proved to increase pain threshold up to the level of surgical analgesia, improve acute and chronic pain as well as coping and resilience, helping to decrease both drug overuse and the costs of pharmacological therapy. The plethora of available data suggests the need for a holistic approach, aiming to take care of the individual as an inseparable mind-body unit in its interplay with the environment, where patient's inner world, his/her experience and cognition are taken into due account as powerful resources for recovery through a phenomenological-existential approach.

Studies investigating the psychosomatic effects of social isolation in animals have shown that one of the physiologic system that gets disrupted by this environment-affective change is the Endocannabinoid System. As the levels of endocannabinoids change in limbic areas and prefrontal cortex during stressful times, so is the subject more prone to fearful and negative thoughts and aggressive behavior. The interplay of social isolation on the hypothalamic-pituitary-adrenal axis and cannabinoid tone triggers a vicious cycle which further impairs the natural body's homeostatic neuroendocrine levels and provokes a series of risk factors for developing health complications. In this paper, we explore the psychosomatic impact of prolonged quarantine in healthy individuals, and propose management and coping strategies that may improve endocannabinoid tone, such as integration of probiotics, cannabidiol, meditation, and physical exercise interventions with the aim of supporting interpersonal, individual, and professional adherence with COVID-19 emergency public measures whilst minimizing their psycho-physical impact., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Brugnatelli, Facco and Zanette.)

Compelling literature has suggested the possibility of adopting hypnotic suggestions to override the Stroop interference effect. However, most of these studies mainly reported behavioral data and were conducted on highly hypnotizable individuals. Thus, the question of the neural locus of the effects and their generalizability remains open. In the present study, we used the Stroop task in a within-subject design to test the neurocognitive effects of two hypnotic suggestions: the perceptual request to focus only on the central letter of the words and the semantic request to observe meaningless symbols. Behavioral results indicated that the two types of suggestions did not alter response time (RT), but both favored more accurate performance compared to the control condition. Both types of suggestions increased sensory awareness and reduced discriminative visual attention, but the perceptual request selectively engaged more executive control of the prefrontal cortex (PFC), and the semantic request selectively suppressed the temporal cortex activity devoted to graphemic analysis of the words. The present findings demonstrated that the perceptual and the semantic hypnotic suggestions reduced Stroop errors through common and specific top-down modulations of different neurocognitive processes but left the semantic activation unaltered. Finally, as we also recruited participants with a medium level of hypnotizability, the present data might be considered potentially representative of the majority of the population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Perri, Bianco, Facco, Di Russo.)

Free will is a complex construct that includes critical reasoning, sense of ownership, and agency. The whole history of hypnosis has been linked to suggestibility. Little agreement has been reached, however, on exactly what we mean by suggestibility, and its role in hypnosis, despite the abundance of studies, hypotheses, and theories published to date. We report on a highly hypnotizable patient with a previous allergy to lidocaine and paradoxical reactions to pharmacological sedation, who underwent oral surgery with mepivacaine for local anesthesia, and hypnosis for sedation. During the procedure, she felt some pain and the hypnotist recommended bupivacaine to ensure lasting anesthesia. While remaining under deep hypnosis, the patient refused to change anesthetic and decided autonomously to continue with mepivacaine (for which she had previously been tested for allergy). Our case clearly shows a preserved, exemplary reasoning and ability to make autonomous decisions diverging from the hypnotist's advice while under deep hypnosis.