Index of Consciousness monitoring may effectively predict and prevent circulatory stress induced by endotracheal intubation under general anesthesia: a prospective randomized controlled trial.

BACKGROUND: The primary objective of anesthesiologists during the induction of anaesthesia is to mitigate the operative stress response resulting from endotracheal intubation. In this prospective, randomized controlled trial, our aim was to assess the feasibility and efficacy of employing Index of Consciousness (IoC, IoC1 and IoC2) monitoring in predicting and mitigating circulatory stress induced by endotracheal intubation for laparoscopic cholecystectomy patients under general anesthesia (GA). METHODS: We enrolled one hundred and twenty patients scheduled for laparoscopic cholecystectomy under GA and randomly allocated them to two groups: IoC monitoring guidance (Group T, n = 60) and bispectral index (BIS) monitoring guidance (Group C, n = 60). The primary endpoints included the heart rate (HR) and mean arterial pressure (MAP) of the patients, as well as the rate of change (ROC) at specific time points during the endotracheal intubation period. Secondary outcomes encompassed the systemic vascular resistance index (SVRI), cardiac output index (CI), stroke volume index (SVI), ROC at specific time points, the incidence of adverse events (AEs), and the induction dosage of remifentanil and propofol during the endotracheal intubation period in both groups. RESULTS: The mean (SD) HR at 1 min after intubation under IoC monitoring guidance was significantly lower than that under BIS monitoring guidance (76 (16) beats/min vs. 82 (16) beats/min, P = 0.049, respectively). Similarly, the mean (SD) MAP at 1 min after intubation under IoC monitoring guidance was lower than that under BIS monitoring guidance (90 (20) mmHg vs. 98 (19) mmHg, P = 0.031, respectively). At each time point from 1 to 5 min after intubation, the number of cases with HR ROC of less than 10% in Group T was significantly higher than in Group C (P < 0.05). Furthermore, between 1 and 3 min and at 5 min post-intubation, the number of cases with HR ROC between 20 to 30% or 40% in Group T was significantly lower than that in Group C (P < 0.05). At 1 min post-intubation, the number of cases with MAP ROC of less than 10% in Group T was significantly higher than that in Group C (P < 0.05), and the number of cases with MAP ROC between 10 to 20% in Group T was significantly lower than that in Group C (P < 0.01). Patients in Group T exhibited superior hemodynamic stability during the peri-endotracheal intubation period compared to those in Group C. There were no significant differences in the frequencies of AEs between the two groups (P > 0.05). CONCLUSION: This promising monitoring technique has the potential to predict the circulatory stress response, thereby reducing the incidence of adverse reactions during the peri-endotracheal intubation period. This technology holds promise for optimizing anesthesia management. TRAIL REGISTRATION:  Chinese Clinical Trail Registry Identifier: ChiCTR2300070237 (20/04/2022).

[Current progress on characteristics of intracranial electrophysiology related to prolonged disorders of consciousness].

Prolonged disorders of consciousness (pDOC) are pathological conditions of alterations in consciousness caused by various severe brain injuries, profoundly affecting patients' life ability and leading to a huge burden for both the family and society. Exploring the mechanisms underlying pDOC and accurately assessing the level of consciousness in the patients with pDOC provide the basis of developing therapeutic strategies. Research of non-invasive functional neuroimaging technologies, such as functional magnetic resonance (fMRI) and scalp electroencephalography (EEG), have demonstrated that the generation, maintenance and disorders of consciousness involve functions of multiple cortical and subcortical brain regions, and their networks. Invasive intracranial neuroelectrophysiological technique can directly record the electrical activity of subcortical or cortical neurons with high signal-to-noise ratio and spatial resolution, which has unique advantages and important significance for further revealing the brain function and disease mechanism of pDOC. Here we reviewed the current progress of pDOC research based on two intracranial electrophysiological signals, spikes reflecting single-unit activity and field potential reflecting multi-unit activities, and then discussed the current challenges and gave an outlook on future development, hoping to promote the study of pathophysiological mechanisms related to pDOC and provide guides for the future clinical diagnosis and therapy of pDOC.

Interoceptive signals shape the earliest markers and neural pathway to awareness at the visual threshold.

Variations in interoceptive signals from the baroreceptors (BRs) across the cardiac and respiratory cycle can modulate cortical excitability and so affect awareness. It remains debated at what stages of processing they affect awareness-related event-related potentials (ERPs) in different sensory modalities. We investigated the influence of the cardiac (systole/diastole) and the respiratory (inhalation/exhalation) phase on awareness-related ERPs. Subjects discriminated visual threshold stimuli while their electroencephalogram, electrocardiogram, and respiration were simultaneously recorded. We compared ERPs and their intracranial generators for stimuli classified correctly with and without awareness as a function of the cardiac and respiratory phase. Cyclic variations of interoceptive signals from the BRs modulated both the earliest electrophysiological markers and the trajectory of brain activity when subjects became aware of the stimuli: an early sensory component (P1) was the earliest marker of awareness for low (diastole/inhalation) and a perceptual component (visual awareness negativity) for high (systole/exhalation) BR activity, indicating that BR signals interfere with the sensory processing of the visual input. Likewise, activity spread from the primary visceral cortex (posterior insula) to posterior parietal cortices during high and from associative interoceptive centers (anterior insula) to the prefrontal cortex during low BR activity. Consciousness is thereby resolved in cognitive/associative regions when BR is low and in perceptual centers when it is high. Our results suggest that cyclic fluctuations of BR signaling affect both the earliest markers of awareness and the brain processes underlying conscious awareness.

Superconscious processes as mental images of a higher order (in the context of telezombification).

OBJECTIVE: Aim: The paper aims to examine superconscious processes as mental images of a higher order in the context of telezombification. PATIENTS AND METHODS: Materials and Methods: The authors used interpretive research paradigm, psychoanalysis, basic principles of hermeneutics, phenomenological approach along with general scientific methods, such as induction, deduction, generalization, etc. CONCLUSION: Conclusions: With the beginning of the russian full-scale attack on Ukraine, russian atrocities in Bucha, Mariupol and other cities and villages of the country, many Ukrainian citizens asked about what has happened to the russian society, the state authorities, who set the goal of destroying Ukraine as a state and all its inhabitants as a nation. Then Ukrainians have labelled the invaders and the authorities of Russia as non-humans. And this is a fair name for them. The fact is that these occupiers and their neo-Nazi leaders have a destroyed, distorted consciousness as a result of which they became incapable of realizing their thought processes. The consciousness of such persons gradually degrades towards animal thinking, the so-called proto-thinking. This is one direction to not realizing one's intentions and actions at the level of both subconscious and partially conscious analysis of primary mental images (images of a first and second orders). The second direction is the role of superconscious processes, in particular mental images of a higher level, which also form the worldview positions of an individual in the process of viewing and listening to certain information, while remaining, at the same time, unconscious until a certain time. Together, these directions form a person's attitude to existing social and worldview problems.

Elements of episodic memory: lessons from 40 years of research.

40 years ago, Endel Tulving published his hugely influential Elements of Episodic Memory (Oxford: Clarendon Press, 1983). For the first time, this discussed the details of episodic memory (i.e. the ability to remember personal past events), including a specific conscious experience. Ten years later, Tulving defined the ability to mentally project oneself in time to be the critical feature distinguishing episodic from semantic memory ('What is episodic memory?' Curr. Dir. Psychol. Sci. 2, 67-70, doi:10.1111/1467-8721.ep10770899). In this conception, the conscious experience of episodic memory captures the experience of reliving a personal event as it was experienced in the past, while the same ability allows a potential symmetry between remembering the past, and our ability to project into an imagined future. With the recent passing of Endel Tulving, this theme issue offers an opportunity to question our understanding of mental time travel in full.This article is part of the theme issue 'Elements of episodic memory: lessons from 40 years of research'.

Episodic memory without autonoetic consciousness.

Ever since Tulving's influential 1985 article 'Memory and consciousness', it has become traditional to think of autonoetic consciousness as necessary for episodic memory. This paper questions this claim. Specifically, it argues that the construct of autonoetic consciousness lacks validity and that, even if it was valid, it would still not be necessary for episodic memory. The paper ends with a proposal to go back to a functional/computational characterization of episodic memory in which its characteristic phenomenology is a contingent feature of the retrieval process and, as a result, open to empirical scrutiny. The proposal also dovetails with recent taxonomies of memory that are independent of conscious awareness and suggests strategies to evaluate within- and between-individual variability in the conscious experience of episodic memories in human and non-human agents. This article is part of the theme issue 'Elements of episodic memory: lessons from 40 years of research'.

Statistical Learning Facilitates Access to Awareness.

Statistical learning is a powerful mechanism that enables the rapid extraction of regularities from sensory inputs. Although numerous studies have established that statistical learning serves a wide range of cognitive functions, it remains unknown whether statistical learning impacts conscious access. To address this question, we applied multiple paradigms in a series of experiments (N = 153 adults): Two reaction-time-based breaking continuous flash suppression (b-CFS) experiments showed that probable objects break through suppression faster than improbable objects. A preregistered accuracy-based b-CFS experiment showed higher localization accuracy for suppressed probable (versus improbable) objects under identical presentation durations, thereby excluding the possibility of processing differences emerging after conscious access (e.g., criterion shifts). Consistent with these findings, a supplemental visual-masking experiment reaffirmed higher localization sensitivity to probable objects over improbable objects. Together, these findings demonstrate that statistical learning alters the competition for scarce conscious resources, thereby potentially contributing to established effects of statistical learning on higher-level cognitive processes that require consciousness.

Propofol disrupts the functional core-matrix architecture of the thalamus in humans.

Research into the role of thalamocortical circuits in anesthesia-induced unconsciousness is difficult due to anatomical and functional complexity. Prior neuroimaging studies have examined either the thalamus as a whole or focused on specific subregions, overlooking the distinct neuronal subtypes like core and matrix cells. We conducted a study of heathy volunteers and functional magnetic resonance imaging during conscious baseline, deep sedation, and recovery. We advanced the functional gradient mapping technique to delineate the functional geometry of thalamocortical circuits, within a framework of the unimodal-transmodal functional axis of the cortex. Here we show a significant shift in this geometry during deep sedation, marked by a transmodal-deficient geometry. This alteration is closely linked to the spatial variations in the matrix cell composition within the thalamus. This research bridges cellular and systems-level understanding, highlighting the crucial role of thalamic core-matrix functional architecture in understanding the neural mechanisms of states of consciousness.

The evolutionary and neurobiological attributes of consciousness: an update. / Ewolucyjne i neurobiologiczne atrybuty swiadomosci: aktualizacja.

Consciousness is most frequently defined as a subjective experience of mental processes. The phenomenon of consciousness has always been a subject of great interest in various fields of science, including psychiatry, and the most prominent scientists have engaged in research on it. The studies performed in recent years have brought about novel data on the evolutionary and neurobiological attributes of this phenomenon. In the first part of the article, the evolutionary concepts of consciousness are presented, going back to the beginnings of life on our planet. They are proposed by such illustrious scientists as Joseph LeDoux, Daniel Dennett, António Damásio, and Arthur Reber. Each of them presents the issue of consciousness in the context of evolution slightly differently. However, there are many similarities concerning the development of the nervous system and mental life. The second part discusses the novel research on the cognitive and neurobiological components of consciousness. Among many researchers of this issue, we chose the achievements of two British authors such as Chris Frith and Anil Seth. The neuroanatomical and perceptive aspects of both the level and context of consciousness are provided. Besides presenting the contemporary evolutionary and neurobiological concepts of consciousness, the article aims to bring closer the profiles of the prominent researchers of neuroscience mentioned here. This term can be translated into Polish as "neuronauka", although our country's most frequently used name is "neurobiologia."

Evaluating the explanatory power of the Conscious Turing Machine.

The recent "Conscious Turing Machine" (CTM) proposal offered by Manuel and Lenore Blum aims to define and explore consciousness, contribute to the solution of the hard problem, and demonstrate the value of theoretical computer science with respect to the study of consciousness. Surprisingly, given the ambitiousness and novelty of the proposal (and the prominence of its creators), CTM has received relatively little attention. We here seek to remedy this by offering an exhaustive evaluation of CTM. Our evaluation considers the explanatory power of CTM in three different domains of interdisciplinary consciousness studies: the philosophy of mind, cognitive neuroscience, and computation. Based on our evaluation in each of the target domains, at present, any claim that CTM constitutes progress is premature. Nevertheless, the model has potential, and we highlight several possible avenues of future research which proponents of the model may pursue in its development.

Children with developmental coordination disorder display atypical interhemispheric connectivity during conscious and subconscious rhythmic auditory-motor synchronization.

Children with developmental coordination disorder (DCD) display difficulties in perception-action coupling when engaging in tasks requiring predictive timing. We investigated the influence of awareness on auditory-motor adjustments to small and large rhythmic perturbations in the auditory sequence to examine whether children synchronize their movements automatically or through planning and whether those adjustments occur consciously or subconsciously. Electroencephalography (EEG) was used to assess functional connectivity patterns underlying different adjustment strategies. Thirty-two children aged 7-11 participated, including children with DCD and their typically developing (TD) peers with and without musical training. All children automatically adjusted their motor responses to small rhythmic perturbations by employing the anticipatory mode, even when those changes were consciously undetectable. Planned adjustments occurred only when children consciously detected large fluctuations (Δ 20%), which required a shift from predictive to reactive strategies. Compared to TD peers, children with DCD showed reduced interhemispheric connectivity during planned adjustments and displayed similar neural patterns regardless of task constraints. Notably, they benefited from rhythmic entrainment despite having increased variability and lower perceptual acuity. Musical training was associated with enhanced auditory-perceptual timing, reduced variability, and increased interhemispheric coherence. These insights are important for the therapeutic application of auditory/rhythm-based interventions in children with DCD.

Breathwork-induced psychedelic experiences modulate neural dynamics.

Breathwork is an understudied school of practices involving intentional respiratory modulation to induce an altered state of consciousness (ASC). We simultaneously investigate the phenomenological and neural dynamics of breathwork by combining Temporal Experience Tracing, a quantitative methodology that preserves the temporal dynamics of subjective experience, with low-density portable EEG devices. Fourteen novice participants completed a course of up to 28 breathwork sessions-of 20, 40, or 60 min-in 28 days, yielding a neurophenomenological dataset of 301 breathwork sessions. Using hypothesis-driven and data-driven approaches, we found that "psychedelic-like" subjective experiences were associated with increased neural Lempel-Ziv complexity during breathwork. Exploratory analyses showed that the aperiodic exponent of the power spectral density-but not oscillatory alpha power-yielded similar neurophenomenological associations. Non-linear neural features, like complexity and the aperiodic exponent, neurally map both a multidimensional data-driven composite of positive experiences, and hypothesis-driven aspects of psychedelic-like experience states such as high bliss.

Prognosis of patients with prolonged disorders of consciousness after brain injury: a longitudinal cohort study.

Background: The findings regarding the prognosis of prolonged disorders of consciousness (PDOC) vary widely among different studies. This study aims to investigate the mortality, consciousness recovery and disabilities of patients with PDOC after brain injury. Methods: A total of 204 patients with PDOC were included in a longitudinal cohort study, including 129 males and 75 females. There were 112 cases of traumatic brain injury (TBI), 62 cases of cerebral hemorrhage (CH), 13 cases of cerebral infarction (CI) and 17 cases of ischemic hypoxic encephalopathy (IHE). The status of consciousness at 1, 2, 3, 6, 12, 18, 24, 36, 48 months of the disease course was assessed or followed up using the Revised Coma Recovery Scale (CRS-R). If the patients were conscious, the disability Rating Scale (DRS) was also performed. The prognosis of different PDOC including coma, vegetative state (VS) and minimal conscious state (MCS) was analyzed. The survival patients were screened for variables and included in multivariate binary Logistic regression to screen the factors affecting the recovery of consciousness. Results: The mortality rates at 12, 24, 36, and 48 months were 10.7, 23.4, 38.9, and 68.4%, respectively. The median time of death was 18 months (8.75, 29). The probability of MCS regaining consciousness was higher than VS (p < 0.05), with the degree of disability left lower than VS (p < 0.05). There was no significant difference between MCS- and MCS+ groups in terms of the probability of regaining consciousness, the extent of residual disability, and mortality rates (p > 0.05). The mortality rate of coma was higher than that of other PDOC (p < 0.05). The mortality rate of MCS was lower than that of VS, but the difference was not statistically significant (p > 0.05). The probability of consciousness recovery after TBI was the highest and the mortality rate was the lowest. The possibility of consciousness recovery in IHE was the least, and the mortality rate of CI was the highest. The cause of brain injury and initial CRS-R score were the factors affecting the consciousness recovery of patients (p < 0.05). Conclusion: The prognosis of MCS is more favorable than VS, with comparable outcomes between MCS- and MCS+, while comatose patients was the poorest. TBI has the best prognosis and IHE has the worst prognosis.

Critical dynamics in spontaneous EEG predict anesthetic-induced loss of consciousness and perturbational complexity.

Consciousness has been proposed to be supported by electrophysiological patterns poised at criticality, a dynamical regime which exhibits adaptive computational properties, maximally complex patterns and divergent sensitivity to perturbation. Here, we investigate dynamical properties of the resting-state electroencephalogram (EEG) of healthy subjects undergoing general anesthesia with propofol, xenon or ketamine. Importantly, all participants were unresponsive under anesthesia, while consciousness was retained only during ketamine anesthesia (in the form of vivid dreams), enabling an experimental dissociation between unresponsiveness and unconsciousness. For each condition, we measure (i) avalanche criticality, (ii) chaoticity, and (iii) criticality-related metrics, revealing that states of unconsciousness are characterized by a distancing from both avalanche criticality and the edge of chaos. We then ask whether these same dynamical properties are predictive of the perturbational complexity index (PCI), a TMS-based measure that has shown remarkably high sensitivity in detecting consciousness independently of behavior. We successfully predict individual subjects' PCI values with considerably high accuracy from resting-state EEG dynamical properties alone. Our results establish a firm link between perturbational complexity and criticality, and provide further evidence that criticality is a necessary condition for the emergence of consciousness.

Beyond primary visual cortex: The leading role of lateral occipital complex in early conscious visual processing.

The study of the neural substrates that serve conscious vision is one of the unsolved questions of cognitive neuroscience. So far, consciousness literature has endeavoured to disentangle which brain areas and in what order are involved in giving rise to visual awareness, but the problem of consciousness still remains unsolved. Availing of two different but complementary sources of data (i.e., Fast Optical Imaging and EEG), we sought to unravel the neural dynamics responsible for the emergence of a conscious visual experience. Our results revealed that conscious vision is characterized by a significant increase of activation in extra-striate visual areas, specifically in the Lateral Occipital Complex (LOC), and that, more interestingly, such activity occurred in the temporal window of the ERP component commonly thought to represent the electrophysiological signature of visual awareness, i.e., the Visual Awareness Negativity (VAN). Furthermore, Granger causality analysis, performed to further investigate the flow of activity occurring in the investigated areas, unveiled that neural processes relating to conscious perception mainly originated in LOC and subsequently spread towards visual and motor areas. In general, the results of the present study seem to advocate for an early contribution of LOC in conscious vision, thus suggesting that it could represent a reliable neural correlate of visual awareness. Conversely, striate visual areas, showing awareness-related activity only in later stages of stimulus processing, could be part of the cascade of neural events following awareness emergence.

Birthing consciousness and the flow experience during physiological childbirth.

PROBLEM: It has been demonstrated that birth without medical intervention conveys significant physical and psychological benefits to the mother and her newborn baby. However, there is a need to include women's subjective experience of physiological birth to understand and promote it. BACKGROUND: The theoretical concept of "birthing consciousness" hypothesizes that women during natural childbirth sometimes experience a specific altered state of consciousness, which is a positive peak experience that resembles "flow" in many aspects. AIM: To investigate the underexplored connection between the physiological mode of childbirth and altered states of consciousness during childbirth. METHODS: Israeli women with childbirth experience were recruited through social media (Facebook groups with a focus on childbirth and motherhood). Participants (n = 766) completed an online survey: the Flow State Scale (FSS) and a demographic questionnaire. FINDINGS: Differences were found between modes of birth as to flow state, as women who experienced physiological childbirth (i.e., with no epidural anesthesia or instrumental interventions) had a higher flow state during birth. DISCUSSION: This link empirically confirms the phenomenon of birthing consciousness. All nine dimensions of the mental state of flow apply to childbirth: challenge-skill balance, action-awareness merging, clear goals, unambiguous feedback, concentration on the task, sense of control, loss of self-consciousness, transformation of time, and autotelic experience. CONCLUSION: Understanding a women's subjective experience during physiological birth can enhance clinical understanding of physiological birth thus promoting positive physiological birth experiences - which has crucial health benefits. We propose that more studies need to be done to promote experiencing flow during physiological birth.

The prevalence of complicated cervical injuries in near-hanging patients without abnormal levels of consciousness or neck signs.

BACKGROUND: Cervical injuries are important complications of near-hanging, which is defined as self-injury by hanging if the patient survives at admission. Previous studies have reported that complicated cervical injuries due to near-hanging are uncommon. The primary aim of this study was to evaluate whether cervical imaging can be safely omitted for near-hanging patients who are alert and have no abnormal neck symptoms or signs. METHODS: This was a retrospective observational study to investigate the prevalence of cervical injuries among hospitalized near-hanging patients between April 2014 and June 2023. The primary outcome was the prevalence of any complicated cervical injuries, which included laryngeal fractures, laryngeal deviations, spinal cord injuries, cervical spine fractures, and blunt cerebrovascular injuries. The primary aim of this study was to determine the primary outcome among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. RESULTS: During the study period, a total of 63 near-hanging patients were hospitalized. Of these, 11 patients (18%) with normal levels of consciousness and no neck symptoms or signs at admission were included. The median age of the patients was 37 years (IQR 27 to 53); 5 (45%) were women, and none had cardiac arrest at the scene. For the primary outcome, no complicated cervical injuries (0%; 95% CI, 0% to 27%) occurred among the small number of near-hanging patients who had normal levels of consciousness and no abnormal neck symptoms or signs at admission. CONCLUSIONS: There were no cases of complicated cervical injuries among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. Further prospective multicenter studies are warranted to investigate whether cervical imaging can be safely omitted in assessments of these patients.

Legal consciousness of psychiatric patients in Israeli hospitals: Awareness and satisfaction.

The paper contributes to the literature on legal consciousness in medical settings by focusing on psychiatric patients' understanding of rights during hospitalization in Israeli psychiatric wards. It asks whether hospital personnel act as agents who promote patients' legal consciousness and whether patients are aware of their legal and social rights during hospitalization. The data for this study were derived from the Patient Experience Survey of Psychiatric Public Hospitals, a comprehensive survey conducted by the Israel Ministry of Health in 2017. The survey included two variables that were used to measure patients' legal consciousness: legal consciousness with hospitalization rights and legal consciousness with social rights. To predict legal consciousness and patient satisfaction, a logistic regression model was employed. The analysis reveals low rates of patients' awareness of hospitalization and social rights, varying between 55 and 66%, respectively. Variations in awareness are not strongly associated with patients' socioeconomic and demographic attributes or with hospital characteristics but are somewhat associated with hospitalization conditions. The data also reveal that awareness of legal rights (whether hospitalization rights or social rights) is likely to increase satisfaction with the hospitalization experience. The analysis underscores a significant finding. Patients' awareness of their legal rights during hospitalization is limited. Interestingly, this awareness is more influenced by the conditions of hospitalization than by the patients' socio-demographic attributes. This research also provides insights into the potential role of legal awareness in shaping patients' attitudes toward treatment and enhancing their satisfaction during hospitalization.

Functional near-infrared spectroscopy: A novel tool for detecting consciousness after acute severe brain injury.

Recent advancements in functional neuroimaging have demonstrated that some unresponsive patients in the intensive care unit retain a level of consciousness that is inconsistent with their behavioral diagnosis of awareness. Functional near-infrared spectroscopy (fNIRS) is a portable optical neuroimaging method that can be used to measure neural activity with good temporal and spatial resolution. However, the reliability of fNIRS for detecting the neural correlates of consciousness remains to be established. In a series of studies, we evaluated whether fNIRS can record sensory, perceptual, and command-driven neural processing in healthy participants and in behaviorally nonresponsive patients. At the individual healthy subject level, we demonstrate that fNIRS can detect commonly studied resting state networks, sensorimotor processing, speech-specific auditory processing, and volitional command-driven brain activity to a motor imagery task. We then tested fNIRS with three acutely brain injured patients and found that one could willfully modulate their brain activity when instructed to imagine playing a game of tennis-providing evidence of preserved consciousness despite no observable behavioral signs of awareness. The successful application of fNIRS for detecting preserved awareness among behaviorally nonresponsive patients highlights its potential as a valuable tool for uncovering hidden cognitive states in critical care settings.