In the context of COVID-19 pandemic, first-line responders (FLR) are exposed to multiple stress factors, ranging from lack of adequate protective equipment to worries about family health due to work-related exposure to the new coronavirus. Therefore, FLR became themselves a vulnerable population that need prevention strategies for professional stress-related disorders (PSRD).

To explore the literature in order to find evidence-based prevention strategies for PSRD in FLR, strategies resulted from other epidemiological crisis situations (MERS-CoV, H1N1, SARS-CoV) that may be applied in the current pandemic.

A literature review was performed through the main electronic databases (PubMed, CINAHL, SCOPUS, EMBASE) using the search paradigm “professional stress-related disorders” AND “first line responders” AND “prevention”. All papers published between January 2000 and June 2020 were included.

Reported prevalence of post-traumatic stress disorder in FLR involved in epidemiological crises was between 10% and 33%. Evidence-based recommendations for PSRD prevention are lacking, and only general advices have been detected. These suggestions were clustered on institutional level (e.g., involving of medical personnel in administrative decisions, encouraging personal initiatives, longer pauses between shifts) and individual level (e.g., training of coping abilities, relaxation techniques, and peer-focused group support). Several guidelines for prevention of mental disorders in workplace exist, but they are not focused on FLR.

The need to elaborate guidelines for prevention of PSRD in FLR can not be overemphasized, especially in the pandemic period, in order to avoid the onset of stress-related complications, and to preserve a good quality of the medical activity.

The regulation of emotions is a psychological process covering the capacity of inhibiting, maintaining or modulating emotions to create a coherent psychological functioning and to enable the individual to live in adequacy with his or her environment.

The aim of the study was to develop an Arabic version of the “Regulation of Emotions Questionnaire-2” (REQ-2T) from Phillips & Power, 2007, and to validate it in a sample of Tunisian university students.

This is a validation study conducted in a sample of 384 Tunisian university students to whom we administered the REQ-2T, the DASS-21 questionnaire and a sociodemographic questionnaire. We tested face and content validity, reliability, and construct validity of the Arabic version of the REQ-2.

Face and content validity were satisfying. The internal consistency was average, with Cronbach’s alpha coefficient ranging from 0.44 to 0.65. The inter-dimensional correlation reflected statistically significant and logical correlations within the REQ-2T. Temporal stability was satisfying with a variable concordance of 0.65. Exploratory analysis revealed four factors similarly to the original version of the questionnaire. Statistically significant correlations were found between the REQ-2T and its external validator (DASS-21).

The REQ-2T demonstrated good psychometric properties, thus this scale can be reliably used as a measure of emotion regulation in the Tunisian population.

No significant relationships.

Neuropsychiatric symptoms may be the first and only manifestation of brain tumours, while classic neurological symptoms and signs may be minimal or absent at first. These patients will often receive psychiatric treatments for prolonged periods before correct diagnosis.

To report the case of a patient with olfactory groove meningioma presenting with neuropsychiatric symptoms as a basis for discussion.

Retrospective review of clinical notes, neuroimaging results and house photos. Literature review.

A 66-year-old woman was brought by police to the psychiatric emergency department Her neighbours had notified authorities of a bad smell, and police found the house was loaded with garbage. The patients reported depressive symptoms in the last 6 months, including apathy, anhedonia, social isolation, decreased appetite and insomnia; loss of basic skills such as cooking or cleaning; she also reported dizziness and two episodes of urinary and faecal incontinence in public. The patient had a history of being medicated for depression between 2000 and 2006. Currently she was taking only alprazolam 1 mg daily. During evaluation she was conscious, oriented and cooperative, with evident hypomimia, psychomotor inhibition and indifferent attitude. Cranial nerve function was preserved except for anosmia. Cranial CT and MRI showed a solid extra-axial tumour of 5.2x3.5x4.9 centimetres compatible with meningioma of the olfactory groove, and she was referred to Neurosurgery for surgical intervention.

This case illustrates the importance of a thorough organic evaluation, including neuroimaging, in the differential diagnosis of patients with atypical symptoms before making a psychiatric diagnosis and instituting treatment.

Cluster B personality disorders are characterized by a higher prevalence of suicidal ideation and behavior than others, and Narcissistic Personality Disorder is no different. Very intense feelings of shame, intolerable for the individual, are often found in patients with Narcissistic Personality Disorder and may have a role in suicidal behavior.

To offer preliminary empirical evidences concerning the relationship between narcissism, shame and suicide ideation.

We administered Pathological Narcissism Inventory (PNI), Test of Self Conscious Affects (TOSCA) and Beck Scale for Suicidal Ideation (BSI) to a sample of individuals with Suicide ideation (n= 65) and a sample of community participants (n=65).

Controlling for age and gender, in the merged sample we found that BSI scores correlated significantly with the vulnerable dimension of narcissism and with TOSCA Interpersonal Shame subscale. In the clinical sample, Interpersonal shame partially mediates the relationship between vulnerable narcissism and suicidal ideation.

Shame seems to play a key role in the relationship between the vulnerable facet of narcissism and suicidal ideation, although the profound mechanism by which it works remains to be understood. Future directions and clinical implications are discussed.

The Unit of Clinical Psychiatry of the University Hospital “Ospedali Riuniti – Ancona”, in collaboration with the Marche Region Health System, is conducting a national observational project entitled “Measures related to the prevention, diagnosis, treatment and assistance of postpartum depressive syndrome”, aiming at promoting women’s Mental Health, particularly in pregnancy and peripartum period.

The primary objective is implementing all measures/interventions needed to promptly screening, early diagnosising, and supporting/caring women with mental health disease during pregnancy and peripartum period. A dedicated training program was performed by our clinical team belonging to the Peripartum Psychiatry Outpatient Service of the Unit of Clinical Psychiatry, at the University Hospital “Ospedali Riuniti”, Ancona, Italy, to a selected audience of Gynecologists/Obstetricians/Nurses/Psychologists/Psychiatrists/GPs and Pediatricians.

The training program is a 2-days residential course, held on 21-22th September, 2020. After the training program, all participants (n= 70) were asked to provide an informed consent and complete an online questionnaire to evaluate knowledge/opinions/experiences and clinical practices in the field of depression in pregnancy and postpartum.

A 40-items questionnaire investigated: a) general attitude in performing screening of depression/anxiety during pregnancy; b) overall knowledge about peripartum depression; c) overall knowledge about management/treatment; d) how physicians manage patients with peripartum depression/anxiety (i.e., how they perform screening/diagnosis/treatment during pregnancy, their levels of knowledge/confidence about psychopharmacology in pregnancy).

The findings of the residential course may allow clinicians to adequately inform and help in drafting a preventive, screening and management program able to assist regional stakeholders in the prevention, diagnosis, treatment and assistance of perinatal depression.

No significant relationships.

No significant relationships.

A pregnant woman’s bond with her fetus and the quality of the prenatal attachment can be determined by numerous variables.

Determine the socio-demographic and clinical factors’ effect on prenatal attachment.

We conducted a transversal descriptive study in a first line clinical practice center and in an university gynecology-obstetrics department. The Prenatal Attachment Inventory (PAI) was used to assess maternal-fetal attachment.

For the 125 pregnant women that participated in our study, 99,2% were married with consanguinity for 14,4%. The mean marriage duration was 4 years and 3 months. Women were illiterate in 3,2% and more than the half (54,4 %) were unemployed. On average, the current pregnancy was their second one. Pregnancy was spontaneous in 85,6%, unplanned in 71,2% and not desired in 29,6%. Sex of the fetus was not desired by the mother in 40,8%. Dysgravidia complicated 32% of the pregnancies with hospitalization in 25,6%. Fetal health problems were detected in 7,2%. A psychiatric trouble has been reported by 4% of the pregnancies. The total score of PAI ranged from 27 to 82 in our sample. We found a statistically significant negative correlation between PAI and duration of marriage (p=0,012); PAI and gestation number (p=0,039) ; and a correlation between PAI and the planning of the pregnancy (p=0,030).

Socio-demographic and clinical factors should be taken in consideration while evaluating pregnant women at risk of perinatal psychological difficulties.

No significant relationships.

Alzheimer’s disease (AD) is a degenerative brain disease and the most common cause of dementia. Evidence suggests that various cytokines, including interleukins (IL) IL-6, IL-10, IL-12 are actively involved in the pathogenesis of AD. The role of IL-17 and IL-23 is less clear.

To investigate the correlations between IL-17, IL-23, and neurocognitive scales in patients with Alzheimer’s disease.

The study included 45 patients: 15 patients with Alzheimer’s disease and 30 patients without cognitive deficit (control group). Clinical and psychometrical methods were used: Mini Mental State Examination (MMSE) scale; Montreal Cognitive Assessment (MoCA), Frontal Assessment Battery (FAB), Alzheimer Disease Assessment Scale-cognitive (ADAS ̶ cog). Serum levels of cytokines of IL-17 and IL-23 were analyzed by sandwich ELISA on “Chem Well 2900” immunoanalyzer (Awareness Technology, USA).

A significantly positive correlation was observed between IL-17 and IL-23 for all AD patients (r =0.723, p=0.002). A significant inverse correlation was observed between serum concentration of IL-17 and MoCA score (r=˗1.0, р≤.0001) and IL-23 and MMSE score (r=˗0.553, р=0.032) in all AD patients. However, no other significant correlations were found between IL-17 and the scores MMSE, FAB, ADAS ̶ cog and between IL-23 and the scores MoCA, FAB and ADAS ̶ cog.

Proinflammatory cytokines (such as IL-17 and IL-23) have been associated with cognitive impairment. However, the complicated relationships of the two cytokines with the pathogenesis of AD need to be further investigated in the future.

No significant relationships.

Galactorrhea wiht antidepressants SSRIs or SNRI is a rarely adverse effect. Some authors believe that the risk of galactorrhea in women who use SSRIs is 8 times higher than in patients treated with other types of drugs. Serotonin is believed to be a potent physiological stimulator of prolactin release.Prolactin stimulates the growth of the mammary glands and the galactorrhea. The SSRIs would activate the serotonergic pathways, these in turn would stimulate the release of prolactin directly in the pituitary and in the hypothalamus, inhibiting the release of dopamine and increasing the release of stimulating factors. The main inhibitor of prolactin secretion is dopamine.

The objective is to reveal this rare complication through the report of a clinical case

A 45-year-old woman with a diagnosis of mixed anxiety-depressive disorder. Treatment with 20 mg of escitalopram was started, with a good therapeutic response, but with breast pain and swelling. She was switched to duloxetine 60 mg, with a good response and adequate tolerance. At 6 months of treatment, she begins to present breast pain and yellow-green breast discharge, with elevated prolactin levels and normal cranial MRI.

She was diagnosed with functional hyperprolactinemia, and treatment with vortioxetine was started. Finally, the Prolactin levels normalize.

Galactorrhea is a very rare and annoying side effect that can lead to discontinuation of treatment and requires a change in the therapeutic strategy.

No significant relationships.

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder characterized by neuropsychiatric symptoms before progressing to seizures, complex movement disorder, autonomic dysfunction and hypoventilation.

Presenting a review of the psychiatric manifestations of anti-NMDAR encephalitis.

Search on Pubmed® and Medscape® databases with the following keywords: “psychiatric”, “anti-NMDA receptor encephalitis” and “anti-NMDAR encephalitis”. We focused on data from systematic reviews and meta-analyzes. The articles were selected by the authors according to their relevance.

Studies show that 77% to 95% of patients with anti-NMDAR encephalitis initially present psychiatric manifestations. Age and sex distribution are young women, and the frequency of cases is lower after 40 years of age. The most common psychiatric symptoms are agitation (59%) and psychotic symptoms (54%). The psychotic symptoms more common are visual (64%), auditory (59%) hallucinations and persecutory delusions (73%). Catatonia is described in 42% of patients. Antipsychotic treatment induces an adverse drug reaction (33%), the neuroleptic malignant syndrome represents 22% of the cases. Delays in distinguishing this disease from a psychiatric disorder can have serious complications, with a mortality of up to 25% in patients receiving limited or delayed immunotherapy.

It’s important to consider anti-NMDAR encephalitis in the differential diagnosis of patients with an acute onset psychosis or unusual psychiatric symptoms. Antipsychotic treatment should be use with caution when suspected or confirmed anti-NMDAR encephalitis. Without appropriate treatment, patients may suffer a protracted course with significant long-term disability or death. A clinical index of suspicion is required to identify patients who would benefit from cerebrospinal fluid testing and immunotherapies.

No significant relationships.

When New York City became an epicenter of the COVID-19 pandemic, healthcare workers from an array of specialties were deployed to work on general medicine units with limited time for clinical retraining.

This study assesses the subjective experience and perceived preparedness of a cohort of non-internal medicine clinicians who were deployed to assist with inpatient management of patients with COVID-19 in the Spring of 2020.

An online survey was distributed to clinicians (residents, fellows, attendings, nurse practitioners, and physician assistants) who cared for patients in roles outside their usual specialties during the pandemic at the Montefiore Health System in the Bronx, NY.

85/169 (50.3%) clinicians responded. 16.5% reported strong feelings of preparedness prior to deployment (≥7/10 Likert scale). ‘Access to appropriate and efficient review materials prior to deployment’ was ranked as 6/10, overall level of stress as 8/10 and concern for contracting COVID-19 while deployed as 8/10. Responses regarding ‘general feelings of preparedness’ had a weak negative association with ‘feelings of frustration about one’s circumstance’ (r= -0.39, p<0.001). Weak negative associations were found between feelings of ‘access to adequate review materials’ and ‘overall stress levels’ (r= -0.31, p<0.001). A moderate positive association was found between ‘feelings of access to adequate review materials’ and ‘feeling on top of one’s work responsibilities’ (r= 0.40, p< 0.001).

The majority of respondents did not feel adequately prepared to care for patients with COVID-19 prior to deployment and had both high stress levels and fear of contracting COVID-19 in the first wave of the pandemic.

No significant relationships.

Burnout syndrome concerns 27.8% of the general working population against 37% among doctors.

This study aimed to report the prevalence of burnout among health care professionals in medical oncology in Tunisia.

This was a cross sectional study including health care professionals in medical oncology working in public hospitals in Tunisia. It was carried out from 15 January 2019 to 15 June 2019. Health profeessionals were asked to answer the Maslach –Burnout Inventory Test. Three scores allowing to locate the burn-out state of the person: the Score of emotional exhaustion (SEE), the Depersonalization score (SD) and the Score of personal achievement at work (SAP).

Le taux de participation était de 58,3%. La combinaison d’un SEE élevé, d’un SD élevé et d’un SAP bas définit le syndrome de Burn-out. Le SEE était élevé chez 44 travailleurs (63%), indiquant un épuisement émotionnel sévère. Un SD élevé a été trouvé chez 37 répondants (53%). La majorité des participants (59%) avaient un PAS faible. Le burnout est défini par l’association chez la même personne d’un épuisement émotionnel élevé, d’une dépersonnalisation élevée et d’un faible rendement personnel. Cela a été trouvé chez 15 des participants (21%). Selon l’étude analytique, le sexe féminin était significativement associé à un SEE élevé, un SAP bas et un épuisement global. Le travail de nuit était significativement associé à un degré élevé de dépersonnalisation et à un degré élevé d’épuisement général.

Burnout is linked to an increasingly ergonomic load. Health care professionnel, particularly in oncology, are frequently faced to this syndrome.

Clinical pathways (CPWs) are tools used to guide evidence-based healthcare. They translate clinical practice guideline recommendations into clinical processes of care within the characteristics of a healthcare institution. There are few studies about the impact of CPW in the field of Psychosis in terms of adequacy to their recommendations and clinical outcomes.

PSYCHSTAGE project has been designed to study the adjustment of psychosis clinical care to a CPW based in a Clinical Practice Guideline according to a clinical staging model in a network of psychiatric services covering 580.000 inhabitants in a University Hospital in Madrid.

Retrospective and observational study in a sample of 1780 subjects 18 years old or above, diagnosed with schizophrenia and other psychosis. Socio-demographic and clinical variables were collected from clinical records, including ICG, GAF and DAS at the time they were included in the study. Clinical stage was established according to McGorry model at the same time. CPW was analysed in 1,391 subjects with 15,254 care events using a Process mining method. Process discovery, process checking and process enhancement analysis have been used.

Patients were grouped according the clinical stage. 9,2% were in stage 2; 18,5% in 3a; 47% in 3b; 22,1% in 3c and 4,1% in 4. A different CPW is represented for each clinical stage in routine practice. Then, every pathway is compared with the recommendations in the established Psychosis CPW.

Process mining can be a useful tool for the study of CPW in the field of psychosis

Designer drugs, as a term, first came about in the 1980s. Most of these “designer drugs” have synthetic cannabinoids and other psychoactive formulas difficulty to detect.

A 28 year man was referred to the hospital.

CT brain and EEG were also normal.

Among 7 days before attending the hospital the patient had a strange behaviour. He was staying like in changed reality. The day before admission he got irritable in the evening was reporting that he could hear animal’s imperative voices “we together with squirrel, dolphin visited giraffe, that someone told to jump from the window”. That symptoms were temporary after that he was shocked when realized that he was in a room. The patient has the history of marihuana use in the past 5 years, periodically. There is no evidence data about the usage of other narcotic substances. On examination he was alert, sitting on a same place looking at one point, sometimes trying to find something or suddenly standing and trying to go somewhere. He has a change of catatonic stupor and excitement. The psychomotor activity was changeable. While observing the patient during few days several times he disrobed all his clothes, staying or laying on a bed or suddenly freezing in one pose.

Taking into account clinical symptoms, the patient developed, the conclusion was made about connection of patients’ oneiroid catatonia with the usage of “Spice” or “Designer drug”. Thus, designer drugs may sound like a safer alternative, but often can lead to serious mental disturbances.

No significant relationships.

Treating pregnant women with bipolar disorder is among the most challenging clinical endeavors. Patients and clinicians are faced with difficult choices at every turn, and no approach is without risk. Many primary mood stabilizers have been associated with risk of congenital malformations. In the last 15 years, there has been an increase of antepartum use of atypical antipsychotic drugs, many of which could be viable alternatives to mood stabilizers. Electroconvulsive therapy has been recommended as a safe and efficacious treatment of bipolar depressive and manic episodes in pregnant women.

This case presents a 24-year-old woman, with COVID-19 infection, that underwent an acute manic episode at her 20-weeks-pregnancy. The goal was to stabilize the patient by the use of electroconvulsive therapy.

The patient was admitted in isolation in the psychiatric ward. Treatment was started with olanzapine 20mg/d and lorazepam 4mg/d. The patient maintained psychotic agitation that required higher dosage, while on the second week of isolation the PCR test was negative. After six weeks of treatment severe manic symptoms continued and electroconvulsive therapy was started.

She received 10 electroconvulsive therapy sessions. The patient showed a substantial clinical improvement after the seventh administration. She gave birth at 37 weeks, with no complications during labor (Apgar 9/10).

Electroconvulsive therapy has been shown as a suitable option for patients with severe psychiatric disorders in the pregnancy period, either medication resistant illness and psychotic agitation.

No significant relationships.

Violent Experiences result in economic and social costs for society, impacting on emotions in families, on health (both physical and mental), and overall quality of life, causing potential damages. Thus, it becomes relevant to do research on this impact, aiming at raising awareness and promoting prevention.

The purpose of the study is to estimate the impact of experiences of violence on both physical and mental health taking into account variables such as age, gender, and marital status.

This is a cross-sectional study sampling 1407 Portuguese speaking adults, with an age average of 42 years old (DP=17.28). The measures used were: The SF-36 questionnaire to assess quality of life, physical and mental health, and the Experiences of Violence Questionnaire.

The sample was divided into two groups (victims and non-victims). The group of participants that were not subjected to violence presents more positive results. In relation to the comparison between genders, it was verified that males present more positive results having into account all dimensions SF-36 when compared to women. Also, older participants (53 years old or more) presents lower results of general health.

Violence and health, increasingly related due to the impact it has on the subjects’ physical and mental health and quality of life.

No significant relationships.

People with a schizophrenia experience higher levels of stigma.

Our aim was to explore the relationship between internalized stigma, depression and quality of life (QoL) in these patients.

This is a cross-sectional and analytical study including 37 stabilized patients with schizophrenia or schizoaffective disorder followed up in the outpatient psychiatry department at Hedi Chaker hospital university of Sfax, between August and October 2019. The Internalized Stigma of Mental Illness scale (ISMI-29) was used to assess internalized stigma and its five dimensions. We used the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF) to assess QoL and the Calgary Depression Scale (CDS) to evaluate depression.

73% of these patients were followed for schizophrenia and 27% for schizoaffective disorder. The global mean score of ISMI was 71.95. The mean scores of alienation, stereotype endorsement, perceived discrimination, social withdrawal and stigma resistance were 15.16, 16.54, 12.95, 15.65 and 11.38, respectively. The Q-LES-Q-SF mean score was 65.51. According to CDS, 18.9% of patients had depression with a mean score of 2.27. Internalized stigma scores (global and the five dimensions scores) were significantly and negatively associated with QoL enjoyment satisfaction score (respective p: p<0.001;p<0.001; p=0.004; p<0.001; p<0.001; p<0,001; p<0.001). Global ISMI score and the four first dimensions scores were positively associated with depressive patients (respective p: p=0.002, p<0.001, p=0.025, p=0.001 and p=0.003) while stigma resistance was negatively correlated with depression (p<0.001).

Our results confirmed that internalized stigma is associated with impaired QoL and depression in stabilized patients with schizophrenia-spectrum diagnosis.

Schedule II of the 2013 Mental Health Act is part of the legal framework for involuntary admission to a licensed mental healthcare facility in Malta (Mount Carmel Hospital) for observation.

To identify trends in presenting features cited by registered specialists in psychiatry in Schedule II applications as well as impact of time of day on involuntary admission.

Schedule II forms relating to all involuntary admissions to Mount Carmel Hospital between 01 June 2018 and 01 June 2019 were retrieved from paper files (n=364). Details relating to reason for using this legal framework were recorded and processed through custom linguistic analysis. Timings of application were also assessed. Data Protection permissions to retrospectively access patient files were obtained. All data collected was de-identified at source.

The commonest reason for use of Schedule II was psychosis (n=139). Substance abuse was recorded in 68 cases, with alcohol and cannabinoids the commonest substances cited. 155 instances relate to situations of increased risk, the commonest being aggressive behaviour (n=74). 61 cases recorded suicidal intent. Peak use of this schedule occurs between 17:00 and 18:00, which is outside normal working hours.

Predominance of psychosis as a reason for involuntary admission concurs with trends reported internationally, including recent German, Irish and Dutch reports, as does increased use of involuntary admission with out-of-hours presentations. Practices relating to involuntary admission to a mental healthcare facility in Malta appear to reflect general trends in other European cohorts, despite differing legal frameworks.

Identifying distinct dimensions of negative symptoms in First Episode Schizophrenia (FES) might result in a better understanding and treatment of this invalidating symptomatology.

Aim of this study was to examine negative symptom structure in FES patients using the Positive and Negative Syndrome Scale (PANSS).

All 147 participants, aged 12–35 years, completed the PANSS and the Global Assessment of Functioning (GAF) scale. A principal component analysis with varimax rotation was performed to investigate PANSS negative symptom structure in the FES total sample.

A 2-factor model (i.e. “Expressive Deficits” and “Asociality” dimensions) was identified. Only “Expressive Deficits” domain had a significant negative correlation with baseline GAF score.

This bipartite solution seems to be adequate to describe the phenomenological variety of negative symptoms experienced by FES individuals at the point of entry in early intervention services.

No significant relationships.

The most common psychiatric conditions in epilepsy are depression, anxiety, behavioral, psychotic disorders and cognitive disorders as well as those which can be caused by convulsive seizures.

The aims of the research were to define cognitive and affective impairments in patients with epilepsy and their quality of life. Since the presents of cognitive impairments and affective disorders have a considerable impact on the functioning of patients, their socialization and the level of their disability.

We studied the features of clinical and psychopathological manifestations in patients suffering from epilepsy. The study covered 100 patients (47 men and 53 women) who were in inpatient care. The following psychodiagnostic techniques were used: the test of 10 words of Luria, the MOCA test, the Münsterberg test, Mini-Mult test, the quality of life scale, the Hamilton scale of depression and anxiety.

The following data of the study were observed: 88 % patients had decreased memory, 38% had symptoms of depression, 28% had mild situational or neurotic depression, 8% had moderate depression, 2% had severe depression, 20% had a state of severe anxiety, 16% had symptoms of anxiety. The average rate of quality of life among all examined people was 67.5 out of 100.

The results of the conducted research indicate the need for further study of the features of the comorbid pathology in epilepsy and development and implementation pharmacological and nonpharmacological methods for treatments of epilepsy.