This scenario presents a professional challenge due to the inherent risks associated with a patient experiencing new-onset seizures after a traumatic brain injury (TBI). The physician must balance the immediate need for diagnostic clarity and treatment with the patient’s safety, autonomy, and the potential for long-term neurological sequelae. Careful judgment is required to navigate the complexities of post-TBI epilepsy management, including the appropriate use of diagnostic tools, pharmacological interventions, and patient education, all within the ethical and legal framework governing medical practice. The best professional approach involves a comprehensive evaluation that includes a detailed neurological examination, review of imaging studies, and consideration of electroencephalography (EEG) to confirm seizure activity and characterize its type. This approach prioritizes evidence-based diagnosis and management, aligning with the American Board of Physical Medicine and Rehabilitation’s emphasis on thorough patient assessment and the principles of patient-centered care. It also adheres to ethical guidelines regarding informed consent and the physician’s duty to provide appropriate medical care, ensuring that treatment decisions are based on objective findings and established medical knowledge. An approach that delays definitive diagnostic testing, such as EEG, in favor of solely relying on clinical observation, fails to adequately investigate the underlying cause of the patient’s symptoms. This could lead to delayed or inappropriate treatment, potentially increasing the risk of further seizures and associated complications. Ethically, this approach may fall short of the physician’s duty to diagnose and treat promptly. Another incorrect approach would be to immediately initiate aggressive anti-epileptic drug (AED) therapy without a confirmed diagnosis or clear understanding of the seizure type. This could lead to unnecessary medication side effects, drug interactions, and potentially mask underlying issues that require different interventions. It also bypasses the crucial step of establishing a definitive diagnosis, which is fundamental to effective and safe patient care. Furthermore, an approach that focuses solely on the immediate post-injury period without considering the long-term implications of epilepsy management, such as the patient’s functional recovery, cognitive status, and potential for driving or employment, is incomplete. This overlooks the holistic nature of brain injury rehabilitation and the importance of addressing the broader impact of seizures on the patient’s life. The professional reasoning process in such situations should involve a systematic approach: first, gather all relevant clinical information; second, formulate differential diagnoses; third, order appropriate diagnostic tests to confirm or refute diagnoses; fourth, develop a treatment plan based on evidence and patient-specific factors; and fifth, continuously monitor the patient’s response to treatment and adjust as necessary, always prioritizing patient safety and well-being.

Scenario Analysis: This scenario is professionally challenging because accurately classifying the severity of a brain injury is foundational to appropriate treatment planning, resource allocation, and communication among the interdisciplinary team and with the patient and family. Misclassification can lead to suboptimal care, unmet needs, and potentially adverse outcomes. The clinician must balance objective findings with the subjective experience of the patient and family, while adhering to established diagnostic criteria. Correct Approach Analysis: The best professional practice involves a comprehensive assessment that integrates objective neurological findings, neuroimaging results, and standardized clinical assessment tools designed to evaluate cognitive, motor, and sensory deficits. This approach aligns with the diagnostic criteria outlined by the Centers for Disease Control and Prevention (CDC) and the American Congress of Rehabilitation Medicine (ACRM) for classifying traumatic brain injury (TBI) severity. These guidelines emphasize specific indicators such as duration of loss of consciousness (LOC), post-traumatic amnesia (PTA), and Glasgow Coma Scale (GCS) scores, alongside neuroimaging evidence of structural damage. By systematically evaluating these components, the clinician can arrive at a classification that is evidence-based and clinically defensible, ensuring that the patient receives care commensurate with their injury severity. Incorrect Approaches Analysis: One incorrect approach is to rely solely on the patient’s subjective report of symptoms without objective corroboration. While patient experience is vital, it does not, in isolation, provide the necessary data for severity classification according to established medical standards. This failure to incorporate objective measures can lead to underestimation or overestimation of the injury’s impact, potentially resulting in inadequate rehabilitation or unnecessary interventions. Another incorrect approach is to base the classification exclusively on the initial GCS score obtained in the emergency department. While the GCS is a critical initial assessment tool, it is a snapshot in time and does not capture the full spectrum of injury severity, particularly regarding the duration of LOC or PTA, or the presence of subtle cognitive deficits that may emerge later. Over-reliance on this single metric neglects other crucial diagnostic elements required for accurate classification. A further incorrect approach is to assign severity based on the presence of any neuroimaging abnormality, regardless of its extent or clinical significance. While neuroimaging is important, the interpretation must be correlated with clinical findings. Minor contusions or edema may not necessarily equate to a moderate or severe injury if the clinical presentation is mild. This approach risks overclassifying injuries and misdirecting resources. Professional Reasoning: Professionals should employ a systematic, multi-modal approach to severity classification. This involves: 1) obtaining a detailed history including mechanism of injury, duration of LOC, and PTA; 2) performing a thorough neurological examination; 3) reviewing available neuroimaging; 4) utilizing validated assessment tools for cognitive and functional status; and 5) correlating all findings to established diagnostic criteria. This integrated approach ensures accuracy, facilitates effective communication, and guides appropriate treatment and rehabilitation planning.

Scenario Analysis: This scenario presents a professional challenge due to the inherent complexity of managing post-traumatic brain injury (TBI) symptoms, particularly when they manifest as behavioral and emotional dysregulation. The physician must balance the immediate need to alleviate patient distress and improve function with the ethical imperative to avoid unnecessary or potentially harmful interventions. The nuanced interplay of neurotransmitter systems in TBI recovery necessitates a careful, evidence-based approach that prioritizes patient safety and well-being. Correct Approach Analysis: The best professional practice involves a comprehensive, multi-modal assessment that integrates neuroimaging, neuropsychological testing, and detailed clinical observation to identify specific deficits and potential underlying neurotransmitter imbalances. This approach is correct because it adheres to the principles of evidence-based medicine and patient-centered care, as mandated by professional ethical guidelines and the standards of practice for brain injury medicine. By systematically evaluating the patient’s presentation in the context of their injury and employing diagnostic tools, the physician can develop a targeted treatment plan that addresses the root causes of the symptoms, rather than merely managing superficial manifestations. This aligns with the ethical obligation to provide competent and individualized care. Incorrect Approaches Analysis: One incorrect approach involves immediately initiating pharmacotherapy targeting broad neurotransmitter classes, such as broad-spectrum serotonin reuptake inhibitors or dopaminergic agents, without a thorough diagnostic workup. This is professionally unacceptable because it bypasses essential diagnostic steps, potentially leading to ineffective treatment, adverse drug reactions, or masking of underlying issues that require different interventions. It deviates from the principle of informed consent and judicious use of medication. Another incorrect approach is to solely rely on patient self-report of mood and behavior without objective corroboration or further investigation. While patient experience is crucial, in the context of TBI, subjective reports can be influenced by cognitive deficits, emotional lability, or altered self-awareness. This approach fails to adequately assess the objective neurological and psychological impact of the injury and may lead to misdiagnosis or suboptimal treatment strategies. A third incorrect approach is to dismiss the patient’s behavioral and emotional symptoms as purely psychological sequelae of trauma, neglecting the potential for specific neurochemical dysregulation. This is professionally unacceptable as it fails to acknowledge the biological underpinnings of TBI-related behavioral changes and the significant role neurotransmitter systems play in mood, cognition, and behavior following brain injury. It represents a failure to provide comprehensive care that addresses the full spectrum of TBI consequences. Professional Reasoning: Professionals facing such a scenario should employ a systematic decision-making process. This begins with a thorough history and physical examination, followed by targeted diagnostic investigations (neuroimaging, neuropsychological testing) to characterize the injury and its functional consequences. Treatment planning should be collaborative, involving the patient and their family where appropriate, and should be guided by evidence-based practices and ethical considerations. Regular reassessment of treatment efficacy and patient response is crucial, with adjustments made as needed. The focus should always be on a holistic understanding of the patient’s condition and the development of a personalized, safe, and effective care plan.

This scenario is professionally challenging because it requires balancing the immediate need to manage post-traumatic seizures with the long-term goal of optimizing neurological recovery and minimizing potential side effects of neuroprotective agents, all within the framework of evidence-based practice and patient-centered care. The physician must critically evaluate the evidence for specific agents, consider individual patient factors, and adhere to established guidelines for managing brain injury. The best approach involves a comprehensive assessment of the patient’s seizure activity, neurological status, and overall medical condition to determine the most appropriate anticonvulsant therapy. This includes considering agents with a favorable side effect profile and evidence of efficacy in the context of traumatic brain injury (TBI). Furthermore, it necessitates a discussion with the patient and/or their surrogate regarding treatment options, potential benefits, risks, and alternatives, ensuring informed consent. This aligns with the ethical principles of beneficence, non-maleficence, and patient autonomy, as well as the professional responsibility to provide evidence-based care. An incorrect approach would be to solely focus on rapid seizure suppression without considering the potential neurotoxic effects or long-term cognitive impact of certain anticonvulsants. For instance, initiating broad-spectrum anticonvulsants without a clear indication or without considering agents with a higher risk of cognitive impairment could be detrimental to the patient’s recovery. Another failure would be to administer neuroprotective agents without robust evidence of efficacy in the acute TBI phase, potentially exposing the patient to risks without clear benefit and diverting resources from proven interventions. Failing to involve the patient or their surrogate in the decision-making process, or proceeding with treatment without adequate informed consent, represents a significant ethical and professional lapse, violating the principle of patient autonomy. Professional reasoning in such situations requires a systematic approach: first, thoroughly assess the patient’s clinical presentation and diagnostic findings; second, consult current evidence-based guidelines and literature regarding pharmacological management of seizures and neuroprotection in TBI; third, weigh the risks and benefits of each potential therapeutic option, considering individual patient factors; fourth, engage in shared decision-making with the patient and/or their surrogate; and finally, continuously monitor the patient’s response to treatment and adjust the plan as necessary.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the patient’s immediate safety and autonomy with the need for comprehensive assessment and intervention following a significant traumatic brain injury (TBI). The physician must navigate the complexities of altered mental status, potential for emergent complications, and the ethical imperative to act in the patient’s best interest while respecting their rights. The rapid deterioration and the presence of family introduce further layers of complexity, demanding swift, informed, and ethically sound decision-making. Correct Approach Analysis: The best professional practice involves a multi-faceted approach that prioritizes immediate medical stabilization and a thorough, systematic neurological assessment. This includes initiating appropriate diagnostic imaging (e.g., CT scan) to identify structural lesions, closely monitoring vital signs and neurological status for any signs of increased intracranial pressure or herniation, and consulting with relevant specialists (e.g., neurosurgery, critical care) as indicated by the initial findings. Simultaneously, efforts should be made to obtain collateral information from family regarding the mechanism of injury and pre-injury baseline, while preparing for a more detailed history and physical examination once the patient is medically stable. This approach aligns with the fundamental ethical principles of beneficence and non-maleficence, ensuring that the patient receives timely and appropriate medical care to prevent further harm and optimize outcomes, while also respecting their potential for future decision-making capacity. Incorrect Approaches Analysis: One incorrect approach would be to solely focus on obtaining a detailed history from the family without initiating immediate medical stabilization and diagnostic workup. This fails to address the potential for life-threatening intracranial pathology that requires urgent intervention. Delaying diagnostic imaging and neurological monitoring could lead to irreversible neurological damage or death. Another incorrect approach would be to proceed with a lengthy and detailed neurological examination and history-taking from the patient, despite their altered mental status and apparent distress, without first ensuring medical stability and ruling out emergent conditions. This could exacerbate the patient’s condition, delay critical interventions, and potentially be futile given the patient’s current cognitive state. A further incorrect approach would be to defer all decision-making to the family due to the patient’s apparent confusion, without first attempting to assess the patient’s capacity and without initiating the necessary medical investigations. While family input is valuable, the physician has a primary responsibility to the patient’s medical well-being and must take steps to assess and manage their condition directly. Professional Reasoning: Professionals should employ a structured approach to managing acute TBI. This begins with a rapid assessment of airway, breathing, and circulation (ABCs), followed by a focused neurological examination and prompt initiation of diagnostic imaging. Concurrent efforts should be made to gather collateral information from family regarding the injury and the patient’s baseline. As the patient’s condition stabilizes, a more comprehensive history and physical examination can be performed, and the patient’s capacity to make decisions should be assessed. Consultation with specialists should be sought early based on the clinical presentation and imaging findings. This systematic process ensures that immediate life-saving interventions are not delayed while also laying the groundwork for comprehensive care and eventual rehabilitation.

Scenario Analysis: This scenario is professionally challenging because it requires a physician to balance the immediate need for diagnostic clarity with the ethical imperative of obtaining informed consent, especially when dealing with a patient whose cognitive capacity may be compromised by a non-traumatic brain injury. The urgency of identifying the cause of the patient’s symptoms must be weighed against the patient’s right to understand and agree to the proposed diagnostic interventions. Failure to navigate this balance can lead to ethical breaches and potential legal repercussions. Correct Approach Analysis: The best professional practice involves a multi-faceted approach that prioritizes patient autonomy while acknowledging the potential for impaired decision-making capacity. This includes a thorough assessment of the patient’s current cognitive status to determine their ability to understand the proposed diagnostic procedures, their risks, benefits, and alternatives. If capacity is deemed impaired, the next step is to identify and consult with the appropriate surrogate decision-maker, such as a legally authorized representative or next of kin, to obtain informed consent. This approach respects the patient’s rights, adheres to ethical principles of beneficence and non-maleficence, and aligns with established medical guidelines for managing patients with suspected brain injuries. Incorrect Approaches Analysis: Proceeding with invasive diagnostic procedures without first assessing the patient’s capacity and, if necessary, obtaining consent from a surrogate decision-maker represents a significant ethical and regulatory failure. This bypasses the fundamental right to informed consent, which is a cornerstone of medical ethics and patient rights. It can be construed as battery or negligence, as it involves performing medical interventions on an individual without their valid permission. Furthermore, it fails to uphold the principle of patient autonomy, even when that autonomy may be compromised. Another incorrect approach would be to delay necessary diagnostic investigations indefinitely due to uncertainty about capacity, potentially leading to a worsening of the patient’s condition or a missed opportunity for timely intervention. While caution is warranted, a complete cessation of diagnostic efforts is not ethically justifiable when a patient is clearly unwell and in need of evaluation. Professional Reasoning: Professionals should employ a systematic decision-making process when faced with patients who may have impaired decision-making capacity. This process begins with an objective assessment of the patient’s current cognitive function relevant to understanding the proposed medical intervention. If the patient demonstrates sufficient capacity, informed consent is obtained directly from them. If capacity is found to be lacking, the physician must then identify the legally recognized surrogate decision-maker and engage them in the informed consent process, ensuring they have all necessary information to act in the patient’s best interest or according to the patient’s known wishes. Documentation of these assessments and discussions is crucial.

Scenario Analysis: This scenario is professionally challenging because it requires a physician to interpret complex neuroimaging findings in the context of a patient’s evolving neurological deficits following a traumatic brain injury. The challenge lies in selecting the most appropriate imaging modality to guide immediate management and prognosis, balancing diagnostic yield with resource utilization and patient safety. The physician must consider the limitations and strengths of each technique and how they inform clinical decision-making in a time-sensitive situation. Correct Approach Analysis: The best professional practice involves utilizing a CT scan as the initial neuroimaging modality. This approach is correct because CT is readily available, rapid, and highly sensitive for detecting acute intracranial hemorrhage, skull fractures, and mass effect – critical findings that require immediate intervention in the acute phase of traumatic brain injury. Its speed and accessibility make it the gold standard for initial assessment in emergency settings, directly informing decisions about surgical intervention or intensive care management. This aligns with established clinical guidelines for the management of TBI, prioritizing the rapid identification of life-threatening injuries. Incorrect Approaches Analysis: Utilizing an MRI scan as the initial neuroimaging modality is professionally unacceptable in this acute setting. While MRI offers superior soft tissue contrast and detail, it is significantly slower to acquire, less readily available in emergency departments, and more prone to artifact from metallic implants or patient movement. This delay in obtaining critical information about acute hemorrhage could lead to adverse patient outcomes. Employing a PET scan as the initial neuroimaging modality is also professionally unacceptable. PET scans are primarily used to assess metabolic activity and are not designed for the rapid detection of structural abnormalities like acute bleeding or edema, which are the immediate concerns in acute TBI. Their use in this context would be a misallocation of resources and would fail to provide the necessary information for acute management. Relying solely on a clinical examination without any neuroimaging in the acute phase of moderate to severe TBI is professionally unacceptable. While clinical assessment is crucial, the potential for subtle but significant intracranial pathology that is not clinically apparent necessitates objective imaging to guide appropriate and timely treatment, especially when there are focal neurological deficits. Professional Reasoning: Professionals should approach such situations by first identifying the immediate clinical question. In acute TBI, this is typically the presence and extent of intracranial hemorrhage or mass effect. Next, they should consider the available diagnostic tools and their respective strengths and weaknesses in addressing that question. The urgency of the situation and the need for rapid, actionable information will dictate the choice of modality. Finally, they must integrate imaging findings with the patient’s clinical presentation to formulate a management plan, always prioritizing patient safety and evidence-based practice.

This scenario presents a professional challenge due to the evolving nature of biomarkers in brain injury medicine and the need to integrate novel research findings into clinical practice responsibly. Clinicians must balance the potential benefits of new diagnostic and prognostic tools with the imperative to ensure patient safety, evidence-based care, and appropriate resource allocation. Careful judgment is required to discern between preliminary research and clinically validated applications. The best professional approach involves a systematic evaluation of emerging biomarkers within the established framework of clinical evidence and regulatory approval. This entails critically appraising the scientific literature for robust validation studies, assessing the biomarker’s performance characteristics (sensitivity, specificity, predictive value), and considering its potential impact on patient management and outcomes. Furthermore, it requires understanding the current regulatory landscape for diagnostic tests and therapeutic interventions, ensuring that any proposed use aligns with FDA guidelines or equivalent regulatory bodies for medical devices and diagnostics. Ethical considerations, such as informed consent and avoiding premature adoption of unproven technologies, are paramount. An incorrect approach would be to immediately incorporate a novel biomarker into routine clinical practice based solely on preliminary research findings or anecdotal evidence. This fails to adhere to the principles of evidence-based medicine, which mandate rigorous scientific validation before widespread adoption. Such an approach risks misdiagnosis, inappropriate treatment decisions, and potentially exposing patients to unproven interventions without adequate understanding of their risks and benefits. Ethically, it violates the principle of non-maleficence and can lead to patient harm and erosion of trust. Another professionally unacceptable approach is to dismiss the potential utility of a biomarker solely because it is not yet widely recognized or incorporated into standard clinical guidelines. While caution is necessary, an overly conservative stance can hinder the advancement of patient care by delaying the adoption of beneficial innovations. This approach may fail to recognize the dynamic nature of medical knowledge and the importance of staying abreast of cutting-edge research that could ultimately improve patient outcomes. A further incorrect approach involves prioritizing the commercial interests or perceived novelty of a biomarker over its demonstrated clinical utility and safety. This can lead to the promotion and use of tests or interventions that have not undergone sufficient scrutiny, potentially exploiting patient vulnerability and misallocating healthcare resources. Regulatory compliance and ethical patient care must always supersede commercial pressures. The professional decision-making process for similar situations should involve a multi-faceted approach: 1. Evidence Appraisal: Rigorously evaluate the quality and strength of scientific evidence supporting the biomarker’s efficacy, reliability, and clinical utility. 2. Regulatory Awareness: Understand the current regulatory status of the biomarker or related diagnostic/therapeutic tools. 3. Clinical Context: Assess how the biomarker fits within the existing clinical pathway and its potential to improve diagnostic accuracy, prognostication, or treatment selection. 4. Ethical Considerations: Ensure patient safety, informed consent, and equitable access to care. 5. Collaboration: Consult with colleagues, experts, and relevant professional organizations to gain diverse perspectives. 6. Continuous Learning: Stay updated on emerging research and evolving best practices in the field.

Scenario Analysis: This scenario presents a critical clinical decision point following a severe traumatic brain injury (TBI). The challenge lies in balancing the immediate need to manage intracranial pressure (ICP) and prevent secondary brain injury with the potential risks and long-term implications of surgical intervention. The physician must consider the patient’s overall clinical status, the specific characteristics of the injury, and the evidence-based guidelines for surgical management of TBI, all within the framework of patient autonomy and beneficence. Correct Approach Analysis: The best professional practice involves a comprehensive assessment of the patient’s neurological status, including serial neurological examinations, ICP monitoring, and advanced neuroimaging. Based on this data, a decision is made to proceed with a decompressive craniectomy if there is evidence of refractory intracranial hypertension unresponsive to medical management, or if there is significant cerebral edema posing a risk of herniation. This approach is ethically justified by the principle of beneficence, aiming to preserve brain function and life by reducing pressure. Regulatory guidelines, such as those from the American Association of Neurological Surgeons (AANS) and the Brain Trauma Foundation, support decompressive craniectomy in select cases of severe TBI with elevated ICP. This intervention is considered when medical management alone is insufficient to control dangerously high ICP, thereby preventing secondary ischemic injury and herniation. Incorrect Approaches Analysis: Proceeding directly to a craniotomy without adequate ICP monitoring or evidence of refractory intracranial hypertension would be an inappropriate approach. A craniotomy, typically performed for lesion removal or access to the brain, is not the primary intervention for managing diffuse edema and elevated ICP in the acute phase of severe TBI. Its use in this context without clear indication could expose the patient to unnecessary surgical risks without addressing the underlying hemodynamic instability. Another incorrect approach would be to solely rely on medical management without considering surgical decompression when ICP remains persistently elevated despite maximal medical therapy. This failure to escalate care when indicated violates the principle of beneficence and could lead to irreversible brain damage or death due to uncontrolled intracranial hypertension. Finally, proceeding with any surgical intervention without obtaining informed consent from the patient’s legally authorized representative, or without documenting the rationale and discussion of risks, benefits, and alternatives, would constitute a significant ethical and regulatory failure, potentially violating patient rights and professional standards of care. Professional Reasoning: Professionals should approach such cases by first establishing a clear understanding of the patient’s current neurological status and the trajectory of their injury. This involves a systematic review of clinical findings and diagnostic imaging. Next, they must consult evidence-based guidelines and best practice recommendations for the management of severe TBI. A multidisciplinary team approach, including neurosurgery, critical care, and neurology, is crucial for optimal decision-making. The process should always include a thorough discussion of treatment options, including risks and benefits, with the patient’s family or surrogate decision-maker, ensuring shared decision-making and adherence to ethical principles.

This scenario presents a professional challenge due to the inherent complexity of assessing the impact of a brain injury on an individual’s functional capacity and the need to balance patient autonomy with ensuring safety and optimal rehabilitation outcomes. The physician must navigate the nuances of subjective patient reporting, objective clinical findings, and the potential for cognitive or emotional impairments to influence self-assessment. Careful judgment is required to develop a rehabilitation plan that is both effective and ethically sound, respecting the patient’s goals while addressing identified deficits. The best approach involves a comprehensive, multi-modal impact assessment that integrates objective functional measures with subjective patient and caregiver reports, and considers the patient’s pre-injury baseline and stated goals. This approach is correct because it aligns with ethical principles of beneficence and non-maleficence by ensuring a thorough understanding of the patient’s needs and limitations, thereby guiding the development of a safe and effective rehabilitation plan. It also respects patient autonomy by incorporating their stated goals and preferences into the assessment and planning process. Furthermore, it adheres to best practices in brain injury rehabilitation, which emphasize a holistic and individualized approach. An approach that relies solely on the patient’s self-reported ability to perform daily tasks without objective verification is professionally unacceptable. This fails to account for potential anosognosia or impaired insight, common sequelae of brain injury, which could lead to an overestimation of capabilities and a failure to identify critical areas requiring rehabilitation, potentially leading to safety risks or suboptimal recovery. An approach that prioritizes the physician’s pre-conceived notions of what a “typical” recovery should look like, disregarding the patient’s unique presentation and goals, is also professionally unacceptable. This violates the principle of patient-centered care and can lead to a rehabilitation plan that is not motivating or relevant to the individual, hindering engagement and progress. It also fails to acknowledge the wide variability in brain injury recovery. An approach that focuses exclusively on addressing the most severe neurological deficits identified in initial diagnostic imaging, without considering the impact of these deficits on the patient’s functional independence and quality of life in their daily environment, is professionally unacceptable. This narrow focus can lead to a rehabilitation plan that does not translate into meaningful improvements in the patient’s life and may neglect the psychosocial and vocational aspects crucial for successful reintegration. Professionals should employ a systematic decision-making process that begins with a thorough history and physical examination, followed by the selection of validated assessment tools appropriate for the suspected deficits. This should be followed by a collaborative discussion with the patient and, where appropriate, their caregivers, to establish realistic goals. The rehabilitation plan should then be developed based on the synthesis of all gathered information, with ongoing reassessment and adjustment as the patient progresses.