The internet is now widely used by people with mental disorders, and it is important to understand whether the internet use can affect the mental state of such people.

The aim of the study was to assess the relation between the internet usage for communication and the quality of the social adaptation in men with mental disorders.

82 male patients with schizophrenia spectrum disorder (F20) were involved into the study (mean age 22±4.3). Methods: SCL-90R, “social circle” inventory (Susan L., Phillips), semi-structured interview of “internet usage” (“communicative internet usage” consists of communication in on-line games, use of the internet social networks for communication, use the internet to find new friends, maintaining relationships with relatives, friends, colleagues.

Two groups of patients were considered: those who use internet for communicative purposes (N=61) and those who do not (N=21).According to the analysis (Mann-Witney U-test, hereinafter significance level *p<0.05), those who use the internet for communication have lower levels of psychotic symptoms (PSY) (U=446*), lower levels of “depression” (U=453*). Those who use the internet for communication have more people in social circle to spend free time (U=910,5*), having the same occupation (U=860*), having the same interests (U=867,5*) and sharing the same values (U=873*).They have more friends (U=804*), peers (U=814*), more women among friends (U=793*), more people to provide instrumental support (U=761,5*).

Patients, who use the internet for communications, have a lower levels of psychopathological symptoms and higher quality of social adaptation. This indicates a possible potential of the internet for mental health rehabilitation.

No significant relationships.

The paper will describe the experience as consultation-liaison psychiatrist during the Covid 19 Pandemic in a private hospital in Madrid, what we have learned and its implications given the considerable and increasing interest in European Consultation-Liaison research.

Following the request of one of the internal medicine department doctors the service was initially provided for patients admitted with the infection but very quickly included relatives and also the hospital staff.

Patients were offered a telephone consultation that in most cases took place on a daily basis. Referrals where made by a doctor, some of them were locums due to the increasing demands of the service since patients from public hospitals were also admitted. Relatives were also referred by doctors and the frequency was more varied, depending on their needs. Members of the multidisciplinary team referred themselves..

Patients and their families felt that the telephone consultation was useful to them. The work with some members of the staff is ongoing and will continue given the toxic levels of stress that they had to face and the changes taking place at the institution at the time.

The COVID-19 pandemic and the short and long term consequences that will follow will increase our understanding the breadth and depth of Consultation-Liaison Psychiatry and the broad perspective required for a comprehensive evaluation and treatment of patients. My experience as psychoanalytic psychotherapist and organizational consultant proved most helpful.

Dr. De Picker reports grants from University Psychiatric Centre Duffel, Johnson & Johnson Belgium and Boehringer-Ingelheim, outside the submitted work.

The assessment of cognitive disorders in schizophrenia is becoming a part of clinical and research practice by using batteries that differ widely in their content. The Brief Assessment of Cognition in Schizophrenia (BACS) was developed to cover the main cognitive deficits of schizophrenia.

The objective of this study was to assess concurrent validity of the Arabic version of the BACS with a standard neurocognitive battery of tests in Lebanese patients with schizophrenia and healthy controls.

A sample of 120 stable inpatients diagnosed with schizophrenia and 60 healthy controls received the Arabic version of the BACS in a first session, and a standard battery in a second session.

The mean duration of completion for the BACS was 31.2 ± 5.4 min in patients with schizophrenia. All tests demonstrated significant differences between controls and patients (p<0.01). A principal components analysis demonstrated that a one-factor solution best fits our dataset (64.8% of the variance). A high Cronbach alpha was found (0.85). The BACS composite scores were significantly correlated with the standard battery composite scores in patients (r=0.78, p < 0.001) and healthy controls (r=0.77, p < 0.001). Also, the correlation analysis between the BACS sub-scores and the standard battery sub-scores showed significant results (p < 0.05). The Arabic-BACS demonstrated high ability to discriminate patients with schizophrenia from healthy controls.

The results showed that the Arabic version of the BACS is a useful tool for assessing cognition in patients with schizophrenia and could be used in clinical practice in Lebanon.

Burnout has become a critical issue in health care systems during the COVID-19 pandemic. Several studies report on the importance of peoples’ sense of coherence (SOC) or control over work for dealing with burnout. SOC implicates a stress-coping capacity involving comprehensibility, manageability, and meaningfulness. However, little is known on how SOC cognitively modulates burnout experiences.

To investigate neurocognitive mechanisms of SOC and burnout in medical professionals.

Forty-one registered nurses were enrolled. We used functional magnetic resonance imaging and measured resting-state brain activity. We identified brain regions associated with SOC and burnout levels by correlating these trait scores to regional fractional amplitude of low frequency fluctuations (fALFF). Subsequently, we investigated whether participants’ levels of SOC impacted their fALFF-burnout association by mediation analysis.

SOC and depersonalization dimension of burnout were negatively correlated (p < 0.01). The fALFF in the mid-dorsolateral prefrontal cortex (DLPFC) correlated positively with SOC scores, and negatively with depersonalization dimension of burnout (p < 0.05). Furthermore, SOC mediated the negative relationship between DLPFC activity and burnout severity (p < 0.05).

Our data suggested that SOC alleviates burnout experience and supports prefrontal activity to prompt cognitive control; they may facilitate flexible shifting of perspective and optimistic reappraisal of work-stress. In effect, workplace-stressors may be acknowledged as being more meaningful than distressing. Without sufficient SOC, frequent exposures to stressors can lead to maladaptive coping to exhibit emotional numbing or depersonalization.

No significant relationships.

Project-based leisure would be conducive to enabling people to project themselves into the future and to move away from the eating disorder, which involves a constant preoccupation with food and one’s body. According to this, travel could be a leisure opportunity that invites to challenge oneself by going out of one’s comfort zone. Coping is a real dilemma for people living with eating disorders and the motivations of a tourism experience could refer to motivation to leave one’s current environment. Consequently, travel would be helpful in reducing the individual’s focus on the illness in a different environment.

The aim of this study is to investigate the use of travel to help people living with eating disorders to live in the present moment and to “let go”. Then, to understand what are the components of travel that are essential for an optimal leisure experience.

This multiple case study uses mixed data from a sample of five participants with an ED and living in France. They were invited to live a tourism experience in Québec for one week. This data collection was before, during and after the trip, using the Experience Sampling Method with a mobile app pocket and guided interviews to assess sensations and emotions in the ecological context of patients.

The trip allowed a letting go and developed a greater ability to live in the present moment. It was a significantly positive moment in the lives of the participants.

Travel associate with digital diary are an innovative approach for ED.

No significant relationships.

The COVID-19 pandemic has caused significant lifestyle changes for the world’s population. The infection poses a threat to mental health due to direct invasion of the central nervous system of SARS-CoV-2, as well as as a source of mental stress associated, in particular, with the deformation of the structure of interpersonal communications under quarantine conditions.

The study was conducted to comparatively study the phenomenology and severity of psychopathological manifestations in quarantined and non-quarantined people during the COVID-19 pandemic.

From April 18 to June 15, 2020, an online questionnaire “Symptom List 90” (SCL-90) was conducted among 837 adults in Russia, Kazakhstan, Belarus and other countries. 426 respondents were in strict home quarantine; 302 observed social distancing, but could go to work; 109 were not socially isolated.

There was a significant difference in the overall severity index (GSI) between strictly quarantine and non-quarantine groups with GSI values of 0.51 (0.24; 0.99) and 0.33 (0.16; 0.75), respectively (p = 0.001). Indicators of anxiety, depression, somatization, obsessive-compulsive symptoms, phobic anxiety, hostility and psychoticism were also significantly higher in quarantined individuals than in non-quarantined individuals (p <0.05).

The results of the analysis indicate that in a pandemic, the most susceptible to psychopathological disorders are those living in the most severe quarantine, while the contingent whose lifestyle changes little under these conditions shows the best indicators of mental health. These data indicate the need to optimize the system of psychiatric preventive and curative care for the population in a pandemic.

No significant relationships.

There is a paucity of information on the exposure of children to violence in Nigeria. The current study aims, as part of a larger study, to explore the experiece of children to violence in their homes in Nigeria.

To determine the prevalence and pattern of violence exposure of children in Ilorin Nigeria.

Cross sectional survey of 1,554 secondary school students aged 11-18 years in Ilorin Nigeria using multistage random sampling technique with proportional allocation was done. Respondents completed the ICAST-CH questionnaire which covers childrens’ exposue to violence. Prevalence of violence exposure was computed.

63.4% (994/1554) of respondesnts had witnessed violence at home. Table 1: Pattern of violence exposure at home in the last 12 months Form Frequency Percentage*

A good number of children in Nigeria might be exposed to violence. There is thus a need for initiative to strengthen family life and control the exposure of children to violence given its potential to cause long standing mental health problems in victims.

No significant relationships.

Children with traumatic brain injury (TBI) are at risk for post-traumatic stress disorder (PTSD). The vast majority of TBI are of mild severity (MTBI), however, they may develop persistent neurophysiological symptoms.

The purpose of this study was to investigate the incidence of PTSD in children with MTBI in Western Greece.

A one-year prospective study was conducted at the Children Hospital of Patras. A total of 175 children aged 6-14 years screened for risk of PTSD at one-week and one-month post-injury, completing the Child Trauma Screening Questionnaire (CTSQ). The Children’s Revised Impact of Event Scale (CRIES 13) was administered to the parents, to inquire their assessment of PTSD in the children. Statistical analysis was performed with IBM SPSS v.22.0

There were 59 (33.7%) children (27.2% boys, 45.9% girls) whose screen result was at risk. At the rescreening one-month postinjury, 9.9% were still at risk. Parents assessed presence of PTSD in 19% of their children at one-week and in 3.9% at one-month post-injury. There was a positive correlation between parenting and child reporting on symptoms of PTSD in children. However, 23.4% mistakenly estimated their children did not experience stress while in fact they did and 24.2% mistakenly estimated the contrary.

The findings revealed the risk of PTSD even in mild TBI, justifying thus the screening to identify these children for intervention strategies. On the other hand, the rescreening demonstrated that not all at-risk children required intervention, since a natural remission in PTSD symptoms was observed one-month post-injury.

Current epidemiological data on the pandemic prevalence of HIV in the world expand the boundaries of the problems associated with the threat of unpredictable spread of infection and the frequency of mental disorders that accompany HIV infection.

Somatogenic mental disorders are determined by the fact that the central nervous system (CNS) is one of the reservoirs for HIV. HIV is indirectly a neurotropic virus and can cause associated neurocognitive impairment (HAND)

In study were used clinical-linguistic examination method for determining linguistic markers for mental disorders in HIV patients who did not receive specific antiviral therapy.

As a result, it was found that 50% of HIV-infected patients not suffering from addiction syndromes or surfactant abuse have mental disorders, which are characterized mainly by disorders of adaptive reactions and mild cognitive impairment. 57.7% of HIV-infected people who do not use surfactants showed a high level of social adaptation. For patients who do not use surfactants, and who have undergone a commission examination before starting ART, the leading psychopathological syndromes are anxiety, anxiety-hypochondria. 44.2% of patients did not have obvious psychopathological symptoms.

Structure of emotional experiences was revealed in patients who recently learned about the burden of a serious chronic disease with the corresponding fear of death and self-stigmatization. Identified linguistic markers are additional signs that can be used by physicians and psychiatrists to diagnose both cognitive impairment and emotional impairment in patients with HIV infection.

No significant relationships.

In their professional work, mental health professionals are continually working with individuals in distress, who may express a wish to end their lives.

To understand the perspectives of mental health professionals towards a person’s right to die.

A mixed-method technique was used: Stage 1 involved a validated online questionnaire sent to all professionals working within the public mental health services in Malta. Stage 2 consisted of a multidisciplinary discussion between six professionals asked to hypothetically manage a terminally ill patient requesting physician-assisted suicide. Thematic analysis was subsequently applied.

The majority of mental health professionals disagreed with allowing a person to commit suicide, even in situations of crippling debt, overwhelming despair and family dishonour. Terminal illness elicited a varied response (Figure 1)

Older professionals and spiritual beliefs negatively impacted acceptability of suicide (Figure 2).

The discussion revealed that professionals would assess individuals requesting to end their lives, with the aim of treating any mental illness and determining mental capacity. Figure 3 highlights factors explored during the assessment. Greatest emphasis is ultimately placed on individual autonomy.

Mental health professionals consider autonomy and self-determination as imperative in evaluating a person’s right to die. Professionals agreed that, after a comprehensive psychiatric assessment and within a regulatory legal framework, they would not impede a person with terminal illness to request physician-assisted suicide, provided that one is acting autonomously. The majority would however conscientiously object to actively assisting the terminal patient in ending one’s life, since this is deemed contradictory to their professional vow of non-maleficence.

The COVID-19 viral pandemic has taken the world by surprise. The pandemic has caused a great impact on the mental health and wellbeing of pregnant women with mental health difficulties. Healthcare providers veered towards video-telemedicine to safely and swiftly provide services to its users.

To determine impact of Video-telemedicine on: 1. Access to Care 2. Ease of Use 3. Quality of Care 4. Difficulties of Use 5. Future Prospects of Video Telemedicine

We have decided to conduct a targeted survey to 100 pregnant women who are known to Perinatal Mental Health services to assess the new methods of contact that the viral pandemic has enforced upon healthcare providers.

Pre-pandemic: video-telemedicine was ranked as least preferred Post-pandemic it is ranked as second favourite. 70.4% of responders have confirmed that video-telemedicine significantly facilitated access to care. 23.3% of responders insisted video-telemedicine made the service better. 50% of responders thought it was much easier to use video options to access their care services needs 95.4% of responders felt that video-telemedicine alternatives should remain post-pandemic

Video-telemedicine options have significantly improved the access and quality of services provided by Community Health Services to pregnant women during the pandemic. Video options can also make it easier to reach critical care without negatively affecting the quality of wholistic care provided, in fact, it can sometimes improve it. It is important that the psychiatric field learn from this pandemic and implement these services permanently. Bigger and wider studies need to be done in the future to support these conclusions.

No significant relationships.

Psychopathological symptoms and cognitive impairment are core features of patients with psychotic disorders. Executive dysfunctions are within the most commonly observed deficits and the Wisconsin Card Sorting Test (WCST) is the test most extensively used for their assessment. Yet, the structure of executive deficits remains unclear, as there may be different underlying processes.

The study’s aims were to explore and compare the network structure of the WCST measures in psychosis and their unaffected siblings.

Subjects were 298 patients with a DSM 5 diagnosis of psychotic disorder and 89 of their healthy siblings. The dimensionality and network structure of the 13 WCST measures were examined by means of the Exploratory Graph Analysis (EGA) and centrality parameters.

The WCST network structure comprised 4 dimensions: Perseveration (PER), Inefficient sorting (IS), Failure to maintain set (FMS) and Learning (LNG). Patient and sibling groups showed a similar network structure and in both cases the network structure was reliably estimated.

Perseveration measures reflect the inability to switch sorting rules when necessary. Scores for the IS dimension can occur when the subject ineffectively tries to test different sorting hypotheses, changing at random the response. FMS reflects the subject’s strategy when he/she is able to find out the sorting rule, but is unable to keep applying that rule long enough. LNG comprised conceptual ability and learning items. The lack of significant difference between network structures is in keeping with results from exploratory and confirmatory studies demonstrating an invariant cognitive factor structure between schizophrenia patients and their unaffected siblings.

The NICE guidelines recommend for mild major depression a range of low-intensity psychosocial intervention of proven effectiveness, as Interpersonal Counselling, and a stepped-care approach.

To assess feasibility and effectiveness of Interpersonal Psychotherapy interventions for the treatment of depression in a consolidated Collaborative Stepped Care Model between primary care and mental health specialists.

103 patients were referred by their PCPs to the Consultation-Liaison Service of Bologna and Modena. Of them, 78 were included in the study and administered self-report instruments and interview, including screening depression, anxiety and daily functioning. Patients were asked to choose one of the available treatment: 1) Interpersonal Counseling (IPC) 6-8 weekly meetings for 30 minutes; 2) IPC for Depression in Primary Care 3 sessions of 50 minutes; 3) a guided self-help intervention. Follow-up were planned at 1, 3 and 6 months. Both patients and PCPs provided a feedback about intervention’s satisfactions.

At the baseline, 39.4% of the patients presented a minor depression/major depression mild and the large majority (75.0%) of them chose IPC, while none of them chose the guided self-help intervention. At follow ups the mean PHQ-9 significantly decreased compared to the baseline (p<0.001); daily functioning increased (WSAS: p<0.001) and anxiety traits improved (STAI: p<0.001). Patient’s general satisfaction with the service received was high (GSQ: 85.9±15.0) as well as PCPs, 62.7% of them expressed high satisfaction for the intervention.

The study emphasised that IPC is an effective and feasible treatment very well suited to the primary care setting for an optimal management of depression.

IIntentionality constitutes an essential phenomenon of psychic life (Brentano, 1874; Husserl, 1917). Its disturbance can be expected in schizophrenia and depression.

To study how such fundamental psychic function is altered in these two diseases.

Phenomenological method allows to deepen in the structure of complex phenomena. Husserl’s analysis of “consciousness of immanent time” helps in studying how intentionality functions in schizophrenia. In depression, we appeal to own previous phenomenological researches revealing three fundamental features: a specific change in body experience; inability to act, feel, think, etc. (inhibition); and alteration, inversion, and suspension of biorhythms.

The intentional arc connects the beginning and the end of a phrase. This arc will keep tenser, the bigger is the potency of the aim of my speech and my capacity to exclude inadequate associations. In schizophrenia intentional arc expands and appear “lax associations” (Bleuler, 1911) and “overinclusion” (Cameron, 1968). Fuchs (2005) argues that also the rest of schizophrenic symptoms represent disturbances of intentionality, e. g., in paranoid ideas an inversion occurs. In depression, its three essential phenomena can be interpreted as different forms of intentionality failure: the compromise of lived body and its consequent loss of transparence lead to incapacity of projecting oneself toward action and future. “Not being able to” (inhibition) means a detention of intentionality. Closely related appears the inability to anticipate. Finally, the alteration, inversion or suspension of biorhythms is temporal and insofar implicates a disturbance of intentionality.

The main features of schizophrenia and depression represent specific forms of alteration of intentionality.

No significant relationships.

The medical novelty of COVID-19 requires a comprehensive study of its impact on various areas of human health, including mental health.

To study the spectrum and severity of psychopathological disorders in previously healthy patients of different age groups who have had moderate and severe COVID-19 pneumonia.

Immediately after stabilization of the physical condition, patients completed the Symptom Checklist-90-R, designed to assess 11 parameters: somatization (SOM), obsessive-compulsive (OS), interpersonal sensitivity (INT), depression (DEP), anxiety (ANX), hostility (HOS), phobic anxiety (PHOB), paranoid ideas (PAR), psychoticism (PSY). Patients with cognitive impairment were excluded.

The study involved 148 patients aged from 26 to 84 years. In the general sample, psychopathological symptoms were detected mainly on the SOM, DEP, ANX, HOS scales. To a lesser extent - on the INT and PAR scales; were practically not determined on the PSY and PHOB scales. Most of the symptoms are significantly more intense in patients over 46 years old (n = 129) compared with the younger population (<46 years old, n = 19). Older patients according to SOM revealed 1.23 points (IQR 0.5) versus 0.85 (IQR 0.7) among young people, DEP - 0.88 (IQR 0.44) vs. 0.47 (IQR 0.44), ANX - 0.66 (IQR 0.44) vs. 0.43 (IQR 0.29), OS - 0.55 (IQR 0.5) vs. 0.31 (IQR 0.25) and HOS - 0.46 (IQR 0.34) vs. 0.29 (IQR 0.09).

Patients recovering from severe COVID-19 pneumonia require psychiatric evaluation and subsequent differentiated psychotherapeutic rehabilitation, especially for the age group over 46.

No significant relationships.

Electroconvulsive therapy (ECT) is considered a gold-standart treatment of severe and treatment-resistant depression. Lack of response to ECT often causes distress in psychiatrists regarding the next therapeutic decisions.

To present a case report of a patient with psychotic depression with partial response to ECT.

Clinical interviews and review of literature using the Pubmed platform.

The authors present a case of a 60 year-old woman admitted for severe depressive episode with psychotic symptoms. Due to lack of response to multiple antidepressive and antipsychotic treatments, 15 sessions of ECT were performed with improvement of behavioral and psychotic symptoms. However, endogenous depressive symptoms with functional impairment persisted. It was then initiated Bupropion 300mg/day resulting in vast improvements on drive, energy and activity levels with restored functionality. Previously to ECT, Bupropion was not considered a valid option due to the psychomotor restlessness that was present. This case exposes the limitations of ECT and the therapeutic conundrums that arise when there is partial response. The symptoms expressed in the patient after ECT course correlate with deficits in noradrenergic and dopaminergic pathways that are involved in endogenous depression. The use of Bupropion, with its effect on noradrenaline and dopamine receptors, may offer a therapeutic lifeline in these cases.

ECT still stands as a gold-standart for severe depressive disorder, especially when several psychopharmacological therapies have failed. In cases of partial response to ECT, the neurobiological correlates of clinical presentation can guide the therapeutic management towards improved outcomes.

No significant relationships.

There is a high degree of comorbidity between serious mental illness (SMI) and substance use disorders (SUD) and cardiovascular disorders. Other life-style related disorders are also common in patients with SMI and SUD. Consequently, comorbidity with somatic diseases contributes to a dramatic reduction in life-expectancy for these patient groups. Physical training has been shown to have positive effects also for mental health, but there has been little systematic use of physical training as part of the treatment for patients suffering from SMI and SUD in Norwegian health care.

To present a new project on physical training for patients suffering from SMI and SUD.

We briefly describe a project in a major Norwegian hospital, where physical exercise will be offered as part of the treatment for patients suffering from SMI and SUD.

The Division for Substance Use and Mental Health now offers an exercise room for inpatients at the main clinic in Tromsø, Norway. The exercise room contains various equipment including treadmills and equipment for strength training. This facility has recently been made available and is currently being used by a selection of patients. A study of user experiences is forthcoming and a systematic study of effects of physical exercise for patients suffering from SMI and SUD is being planned.

Physical exercise has been shown to have positive effects also on mental health. In one major Norwegian hospital, facilities are now offered for inpatients suffering from SMI or SUD. The effects of physical exercise on patients with SMI and SUD will be examined.

No significant relationships.

Bipolar disorder (BD) is a chronic, recurring illness that can lead to serious disruptions in functioning.

To evaluate functionning in this population and to explore the relationship with socio-demographic and clinical features of BD.

This is a descriptive and analytical cross-sectional study including patients with BD (DSM V) in euthymia, followed on an ambulatory basis to the Mood Disorders Unit of the Psychiatry A Department at Hedi Chaker Hospital University of Sfax between January and April 2019. Patients were considered euthymic if they scored less than 7 on the Young Mania (YMRS) rating scale and less than 8 on the Hamilton Depression scale (HDRS-17). The Short Function Evaluation Test (FAST scale) was used to evaluate functionning. Global functional impairment is defined by a total FAST score>11.

We recruited 62 patients with a mean age of 45.65 years (SD=13.3) and a sex ratio of 1.13. 88.7% of patients were followed for BD I and 11.3% for BD II. The mean age of onset was 29.37 years (SD=11.6). The mean numbers of manic and depressive episodes were respectively 3.73 (SD=3.8) and 2.48 (SD=2.9). The mean FAST score was 28.97 (SD=15). Overall impairment was observed in 85.5% of patients. Impaired functionning was significantly more frequent in patients with a history of surgery (p=0.046), in those with a higher number of depressive episodes (p<0.001) and in subjects with partial remission (p=0.01).

Thus, the treatment should target not only the improvement of symptoms but also the reduction of the incapacity of patients.

Studies have consistently found that many individuals with psychosis experience significant delays before receiving treatment. DUP refers to the period between the emergence of psychotic symptoms and the initiation of appropriate clinical treatment.

To review current knowledge on the best approach for patients with schizophrenia (SCZ) and prolonged DUP.

Non-systematic review of literature through search on PubMed database, following the terms “DUP and treatment” and “impact of longer DUP”. Two clinical cases are described.

The clinical cases describe patients with SCZ with DUPs older than 10 years, in whom we could not achieve complete clinical remission after several therapeutic trials and whose prognosis was admitted as reserved. Longer DUP is an independent predictor of poorer outcome in SCZ, including the poor response to treatment and difficulty in achieving remission, predicting treatment resistance. Identifying treatment-resistant patients is crucial due to the importance of initiating clozapine as early as possible since the chances of responding are higher.

DUP is a key prognostic variable in psychosis, revealing the significance of early treatment. Patients with long DUP should be regarded as at high risk of poor recovery. The detection of these patients enables clinicians to avoid unnecessary exposure to ineffective treatments while effective interventions are delayed. However, in view of adverse side effects of clozapine, future studies need to examine relevant predictors to detect accurately non-responders. We also suggest further studies to understand if there is correspondence between DUP and different stages of the disease that justify these results.