Disorders In Egypt Research Articles

Insights into the current state of knowledge, practice, and attitudes of physicians regarding gastrointestinal motility disorders in Egypt

BackgroundGastrointestinal (GI) motility disorders are common in clinical settings, but physicians still lack sufficient understanding and effective management of these conditions.MethodsThis research assessed Egyptian physicians’ knowledge, practices, and attitudes towards GI motility disorders. A cross-sectional survey employing a self-administered questionnaire was carried out among physicians in Egypt. The questionnaire addressed various aspects of physicians’ understanding, practices, and attitudes regarding GI motility disorders. Data analysis was conducted using descriptive statistics and presented as frequencies and percentages.ResultsA total of 462 physicians took part in the study. Although nearly two-thirds of them knew about GI motility studies, a notable proportion lacked adequate knowledge about GI motility disorders. Notably, 84.2% correctly identified dysphagia as a critical symptom suggestive of an upper GI motility disorder. However, 13.4% incorrectly linked hematemesis with an upper GI motility disorder, and 16.7% expressed uncertainty. In terms of practice, around half of the participants encountered a small number of patients with GI motility disorders (less than 5 per week or even fewer). Only 29.7% felt confident in managing patients with motility disorders. Most participating physicians expressed a willingness to participate in training programs focused on motility disorders.ConclusionsThis study underscores a knowledge gap among Egyptian physicians concerning GI motility disorders. It suggests the necessity of tailored education and training programs to improve their competency and practice in this domain.

Clinical characteristics and diagnostic delay in cluster headache in Egypt

ABSTRACT Background Early diagnosis of CH is a cornerstone and it is important to detect causes leading to diagnostic delay. Limited published data exist regarding CH in Egypt, and with no data showing characteristics of CH or causes of diagnostic delay . Aim To investigate clinical characteristics, for CH and detect causes of diagnostic delay in Egypt. Methodology A cross-sectional study was conducted including all patients (age: 18–60 years) with primary headache disorders in Egypt with CH patients consecutively recruited over 1 year. Demographic and clinical characteristics as well as rate of diagnostic delay were collected. Results This registry included 1187 patients with primary headaches over a year. CH accounted for 1.9% . The majority of CH patients were males (82%), and a mean age of 37.9 ± 10 years. The mean age of disease onset was 25 ± 8 years. Sixty-five percent had episodic CH, while 34.8% had chronic CH. Most of the patients (95.7%) had strictly unilateral pain (right side 52.2%, left side 43.5%). Autonomic features were rhinorrhea (91%), ptosis (87%), and lacrimation (78%). Migrainous features were found in 26% of patients. Bout duration of CH lasted on an average of 1–4 months. Time interval of diagnostic delay ranged from 0.5 to 29 years, with a mean diagnostic delay of 9.8 ± 7.9 years. Conclusion This study showed that CHs present 1.9% of primary headache disorders in Egypt, with males more affected than females. the incidence of smoking was higher among CH patients. Marked diagnostic delay was found which necessitate an action toward raising awareness.

Insights into primary care physicians’ detection, intervention and management of patients with substance use disorders in Egypt

Egypt is experiencing an increasing drug problem (cannabis, heroin, amphetamines, pharmaceutical opioids, synthetic cannabinoids). Whilst harm reduction and addiction treatment are provided by government and non-governmental organizations in Egypt, very little is known about physicians experience of handling patient substance use and substance use disorder (SUD) in primary care. A cross-sectional national study of 392 Egyptian Family Physicians (FPs) & General Practitioners (GPs) explored their knowledge, attitude and professional practice regarding management of SUD in primary care, as a first step toward identifying professional development support needs and informing general practice. Findings underscore the need for greater depth of addiction training during undergraduate medical education and in continuing professional development, so that Egyptian FPs/GPs can better prevent harmful substance use, detect patients with SUD, intervene and support those in treatment. This study provides unique information which will inform further development and scale of evidence based SUD brief intervention and treatment within Egyptian primary care.

Unveiling the enigma: physicians' perceptions of functional neurological disorders in Egypt—a cross-sectional study

BackgroundIn medical practice, it is common to see patients who present with physical symptoms for which no disease pathology can be found. The presence of neurological symptoms that are shown to be incompatible with neurological pathophysiology is classically known as “conversion disorder” or “Functional Neurological Symptom Disorder” (FND). While FND is common in Egypt as in the rest of the world, few scientific studies systematically evaluate the degree of knowledge, attitude, and care provided by health care professionals to FND patients. We aimed to assess Egyptian physicians’ perspectives on FND.ResultsA cross-sectional study has been conducted on 152 physicians dealing with FND practicing in Egypt from specialties of psychiatry, neurology, and other specialties. We found that for 45% of the participants, disordered functioning of the nervous system plus psychogenesis was the accepted etiology behind FND. Most participants were significantly not satisfied with their education about FND (p-value 0.01). Psychiatrists and neurologists significantly preferred to use the term “conversion disorder” while other specialties mainly used “psychic” and “Somatization/Somatoform Disorder” (p-value 0.001). Forty-four percent of the participants think they have a good knowledge of functional neurological disorders (FND), while the majority (86.8%) were worried about missing an organic disorder. Psychiatrists were the most confident in diagnosing FND and the most comfortable discussing it with patients (p-values 0.055 and 0.007, respectively).ConclusionHere we highlight the common theme of worry about FND patients prevailing among healthcare professionals who are mostly perplexed about the mechanisms behind FND, and how to communicate these symptoms to other professionals and patients themselves. Future directions need to be devoted to minimizing the gap between the research finding and the currently applied care. Better education and teaching about FND may improve patient care.

Experiences of peer support workers supporting individuals with substance use disorders in Egypt: phenomenological analysis

BackgroundPeer support work for substance use disorders is widely implemented in high-income countries. More research is still needed to understand its applicability in settings which have proportionately low budgets allocated to mental health. Peer Support Workers are individuals who managed to achieve recovery from substance use disorders and help people remain engaged in their recovery and prevent relapse through shared understanding.AimTo investigate the experience of peer support workers providing recovery support to people with substance use disorders in Egypt.MethodsA qualitative phenomenological design was used in which 17 adults working as peer support workers for substance use disorders were recruited by means of purposive and snowball sampling. A semi-structured interview with participants was conducted by phone or video-call. Interviews were transcribed and thematically analysed based on descriptive phenomenology.ResultsThree superordinate themes were identified: role responsibility, Peer Support Workers’ need for organizational and stakeholders’ support, and challenges to the role integrity.Conclusion and recommendationsThe findings indicate the need for national and governmental support to peer support workers engaged with people with substance use disorders in Egypt and educating families and the public about the role of peer support workers in substance use disorders.

Seroprevalence and Genetic Characterization of Toxoplasma gondii among Children with Neurodevelopmental Disorders in Egypt.

Toxoplasma gondii is a parasite with a special predilection for the central nervous system. Toxoplasmosis's contribution to the triggering of many neurodevelopmental disorders was established. This study aimed to detect the seroprevalence and genotypes of T. gondii strains in children with neurodevelopmental disorders. The study included 180 children with neurodevelopmental disorders and 180 children in the control group. Assessment of seropositivity of Toxoplasma IgM and IgG antibodies in patients and controls was carried out. Genetic characterization of T. gondii was obtained by nested polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) technique targeting dense granule gene (GRA6). Our results showed that the overall seroprevalence of T. gondii antibodies in the patient and controls was 35.6% and 11.7%, respectively. Nested PCR showed positivity in 11.1% of the patient group for T. gondii DNA. T. gondii seropositivity rate was significantly high in patients with hydrocephalus and also in patients with epilepsy. Positive nested PCR was significantly high in children with hydrocephalus only. Genotyping using nested PCR-RFLP showed genotype I (80%) followed by atypical strains (20%) with no association with any specific clinical presentation. In conclusion, among toxoplasmosis-positive children with neurodevelopmental disorders, analysis of T. gondii GRA6 locus revealed the predominance of type I genotype followed by atypical strains.

Suicide risk and ideation among patients with substance use disorders in Egypt

ABSTRACT Background Patients with substance use disorders are at high risk for suicidal ideas and behaviors. Prevention of suicide among these patients should be a public health priority. Objective The objective of this study was to investigate the prevalence and correlates of suicidal ideas and suicide risk among patients with substance use disorders. Methods This study included 100 patients with substance use disorders who sought treatment at Zagazig University hospital, Egypt. All participants were interviewed using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text-Revised and rated by Beck Suicide Scale. Drug-related problems were assessed using the Arabic version of Addiction Severity Index. Urine screen for drugs was done for all patients participated in the study. Results Twenty-seven percent of the patients with substance use disorders had suicidal ideas, 22% had suicide risk, and 9% had history of suicidal attempts. Females were 5 times more likely to have suicide risk than males. Unemployed patients were three times more likely to have suicide risk than employed or skilled workers. There was an association between suicide risk and heroin use and alcohol dependence and patients with positive family history of suicide. . Conclusions Suicidal ideas and suicide risk were common among patients with substance use disorders. Female gender, unemployment, heroin use, and alcohol dependence and positive family history of suicide were predictors of suicide ideation and risk in patients with substance use disorders.

Correlation of multi-drug resistance integron genes, blaESBL carriage of Extended-spectrum β-lactamas producing clinical isolates from equine with respiratory disorders

The present study was aimed to identify phenotypical and genotypic antimicrobial characterization of clinical isolates obtained from equine with respiratory disorders in Egypt, as well as the correlation between the β-lactamases and integron genes in clinical isolates. Thirty two clinical isolates were identified as K.pneumoneae (15 isolates); P.aeruginosa (8 isolates); S.zooepidemicus (3 isolates) and S.equi (6 isolates). All isolates showed resistance to more than 3 classes of antibiotic and were considered as multidrug resistance isolates (MRD isolates), K. pneumoneae harbor ctx-M genes and shv-1 gene in highest rate (53.3% and 60% respectively). P.aeruginosa isolates harbor ctx-M genes and shv-1 gene (20% and 33.3% respectively) while S.equi and S.zooepidemicus harbor only ctx-M genes (33.3% and 20% respectively), tem-1 gene was observed in S. equi (66.7%) followed by K,pneumoneae (33.3%) and absent in P.aeruginosa. Significant correlation or association of intI genes with ctx-M genes in K. pneumoneae, P.aeruginosa and streptococcus species was observed, while it was significant with shv-1 in K.pneumoneae and streptococcus species. The significance was at p<0.05. It was concluded that the detection of integrons in most of the bacterial isolates promoters the phenomenon of in depth resistance because of these mobile genetic elements therefore the detection of those mobile gene cassettes in equine may be a keystone of multidrug resistance. Companion animals predominantly contain bla-ctx-M clusters, which might be animal origin, causing quick changes in drug-resistance epidemiology. ctx-M-1 and shv-1 also are commonly found among human pathogens signifying a standard clonal heredity and a possible ESBL dissemination source in farm and livestock.

A systematic review of the prevalence of mental disorders, cognitive impairment and dementia amongst older adults populace in Egypt

AimsThis study aims to review current evidence of the prevalence of mental disorders amongst the elderly populace in Egypt. This will be achieved by estimating the current prevalence and then identifying any sociodemographic correlates with mental disorders.BackgroundMental disorders are the leading cause of disabilities amongst the older adult populace worldwide. The population of the older adult in Egypt is fast growing. According to the Egypt, latest national census in 2014, the population of individuals aged 60 years and above is 6.9% and this is expected to nearly double by the year 2031, with a projection of 11.5% forecasted. In fact, it has been estimated that cost per person of mental health diseases such as dementia in low-income countries is approximately £686 ($868) and £2456 ($3109) in lower-middle income countries like Egypt.MethodElectronic search of five key databases (MEDLINE, PsychINFO, EMBASE, AMED and PubMed) was carried from their date of inception. In addition, reference list scanning, key journal searching, citation searching and relevant internet resources were conducted. Papers were included, if they were published in English, point prevalence studies carried out on older adults Egyptians aged 60 years and above. In addition, mental disorders, cognitive impairment or dementia had to be ascertained using any validated diagnostic tools. Studies which did not meet any of the criteria detailed above were excluded.Result16 studies were included in this review. Four main mental disorders were identified, these are: depression, anxiety, cognitive impairment and dementia. Reported prevalence of Depression, anxiety, dementia and cognitive impairment are 23.7-74.5%, 14.2-72%, 3.66-39.2%, and 1.74 to 51.4% respectively. Anxiety and depression was positively correlated with female gender, increasing age and lower educational status. Also, cognitive impairment and dementia was positively correlated with age, illiteracy or low education. However, there appears to be inconsistencies in the diagnostic tools used.ConclusionThis research brings to the forefront the scale of mental disorders amongst the elderly in Egypt. This may help ensure evidence-based initiatives are put in place and also priority is given to resource allocation for geriatric mental disorders in Egypt.

Assessmentof Adult Attitude towards Mental Illness among Attendees of Family Medicine Outpatient Clinic at Suez Canal University Hospital, Ismailia Governorate

Background: Despite the improvement in healthcare services provided for mentally-ill individuals, yet they often choose not to seek such care or stop taking their medicines due to the surrounding stigma. Many tools in the last years have been developed to assess stigmatizing attitudes towards people with mental illness. Objectives: To assess public attitude towards mental disorders in Egypt and its association with their sociodemographic characteristics. Subjects and Methods: This is a cross-sectional study conducted at the Family Medicine outpatient clinic of Suez Canal University Hospital, Ismailia, Egypt. Two hundred and fifteen participants were interviewed and requested to fill in three questionnaires; demographic questionnaire, socioeconomic status questionnaire, and Attitude to Mental Illness questionnaire. Results: Participants had negative attitudes concerning the fear and exclusion of people with mental illness (19.03 ± 3.86 points). However, they had more positive attitude towards causes of mental illness and the need for special services (11.14 ± 2.02 points), integrating people with mental illness into the community (25.02 ± 4.09 points), understanding and tolerance of mental illness (27.38 ± 3.41 points). Conclusion: Public attitude towards mental illness can be variable. Although the attitudes regarding their fear and exclusion of patients with mental illness were negative; however, we found a huge understanding and tolerance towards mental illness and supported integrating patients with mental illness into the community. Recommendation: Anti-stigma programs are needed to boost people's acceptance of mental illness and strategies to increase social contact of the public with mentally-ill should be considered.

Detection of beta-thalassemia carriers among relatives of patients with thalassemia in Menoufia Governorate

Objectives To detect thalassemia carriers among relatives of patients with thalassemia major. Background Thalassemia syndromes are a group of blood disorders inherited in autosomal recessive manner that cause hemolytic anemia because of the decreased or absent synthesis of a globin chain. Imbalances of globin chains cause hemolysis and impair erythropoiesis. Thalassemia is the most common type of genetic abnormalities in the world. It is one of the most common genetic disorders in Egypt. Thalassemia major is variably referred to as 'Cooley's anemia' and 'Mediterranean anemia.' Thalassemia minor is also called 'beta-thalassemia carrier,' 'beta-thalassemia trait,' or 'heterozygous beta-thalassemia.' Patients and methods This study includes 100 children. All of them are relatives of patients with beta-thalassemia major who attended the Pediatric Hematology Clinic, Menoufia University Hospitals, in the period from May 2015 to November 2017. The age of our group ranged from 6 months to 18 years. Complete blood count, blood film, iron profile (serum iron, serum ferritin, and total iron-binding capacity), and hemoglobin electrophoresis were done for all. Results A total of 30 (30%) children were found to be carriers of beta-thalassemia, 20 (20%) children were found to have iron-deficiency anemia, 20 (20%) children were found to be both carriers of beta-thalassemia and have iron-deficiency anemia, two (2%) children had thalassemia intermediate, two (2%) children had sickle cell trait, and 26 (26%) children were normal. Conclusion Beta-thalassemia carrier status is the most common cause of microcytic anemia among relatives of patients with beta-thalassemia major.

Effect of Parents’ Involvement Interventions in Speech Language Delay among Late Talking Toddlers in Egypt: A Quasi-Experimental Study

Speech language delay is a common developmental problem among Egyptian children. There is paucity of reliable data on parent involvement interventions in speech language problems and of communication disorders in Egypt.

Plasma B-endorphin and cortisol profiles around periparturient period in Friesian Cattle suffering from reproductive disorders in Egypt

The present study aimed to determine plasma β-endorphin and cortisol concentrations in cattle with reproductive disorders (dystocia and retained placenta) and weakness body condition score during periparturient period. Stress may cause an overproduction of beta-endorphins and free radicals. Twenty multiparous Friesian cows weighing 400–650 kg aged 6-10 years and between (3-8) parities at late pregnancy period was used for two months before parturition. From ten days before the expected birth date the birth canal of each animal was monitored by rectal and vaginal palpations, and the body temperature was checked daily to predict the probable time of parturition. Animals were divided into four groups according to parturition disorders’ five animals in each one. First group delivered spontaneously at term with no obstetrical assistance(A), second group delivery was at term but was accompanied by dystocia(B), third group delivery was at term but was accompanied by retained placenta(C), and fourth group delivery was at term but animals showed weakness body condition score (D). Results illustrated that Plasma β-endorphin level in Friesian cattle during pregnancy state increased gradually through gestation period. It reaches its highest level during the third trimester due to stressful state. Also, it reaches its peak at zero time of parturition by appearing its analgesic action. Meanwhile, it decreases gradually towards re-establishment of ovarian cycle. Generally, cows suffering reproductive disorders had a clear impact on blood plasma β-endorphin concentration around parturition process.

Serum Immunoglobulin G, IgM And IgG:IgM Ratio as Predictors for Outcome of Childhood Nephrotic Syndrome.

Background: Nephrtoic syndrome (NS) comes at the top of most prevalent kidney morbidities in Africa constituting 40% of renal disorders in Egypt. Minimal changes NS representing 88% of patients with NS. Glomerular risk factors of NS can be classified into either primary or secondary. Aim of the Work: to estimate serum levels of IgG, IgM, in NS cases comparing them with healthy children in addition to detect the relationship between IgG/IgM ratio and response to treatment with steroids. Patients and Methods: This was an observational cohort prospective study was conducted on 60 subjects recruited from Pediatric Department, Sohag University Hospital during a period of one year from 2015 to 2016. All included patients underwent detailed history taking, medical examination, laboratory investigations, serum albumin, complete blood count with differential white blood cell count, serum immunoglobulin G, immunoglobulin M, were measured in patient groups; group A included 15 patients. They had NS, received steroids for 8 weeks and not respond. They were steroid-resistant Ns (SRNS). group B included 15 patients with SSNS with infrequent relapse, group C included 15 patients with SSNS with frequent relapse, group D included 15 healthy children as a control group. Results: a statistically significant difference was found between groups as regard IgG/IgM ratio. Conclusion: Serum IgM and IgG levels have prognostic value in patients with nephrotic syndrome and can predict the outcome and the frequency of recurrence of disease. There is a close relation between the degree of albuminuria and the levels of serum IgG and M.

Internalized stigma is associated with psychological distress among patients with substance use disorders in Egypt

Internalized stigma is associated with psychological distress among patients with substance use disorders in Egypt

Education of children and young people with autistic spectrum disorders in Egypt

Accessible Summary This paper reviews the present educational needs of children and young people and autistic spectrum disorder (ASD) in Egypt. Children with ASD are largely unrecognised by the educational provision in Egypt. This paper highlights the need for an improved educational programme for children with ASD who also experience an associated learning disability and learning difficulties. It is crucial to develop teacher support programmes and empower teachers to enable children and young people with ASD develop their fullest potential. AbstractThis paper outlines, through a transnational discourse between partners in Egypt and the UK, an overview of the literature on the definition and features of autistic spectrum disorder (ASD) with associated learning needs and health conditions as applied to children and young people in Egypt. As a low‐ to middle‐income country, Egypt has a poor and underdeveloped health, education and social service to support children with ASD and very little research has investigated this phenomenon. This paper adds to the discussion through the shared knowledge and practice in the educational curriculum of children with ASD in Egypt.

The Lived Experiences of Mothers of Children with the Autism Spectrum Disorders in Egypt

The aim of this study was to gain insight into the experiences of mothers caring for children with autism spectrum disorders (ASD) in relation to the early life, resources and to address the consequences of raising a child with ASD in Egypt. Semi-structured interviews were conducted with 14 mothers of children with ASD in Egypt, the children were aged 5–14 years old (mean: 7.3 years). Data were thematically analysed. Results revealed that life with ASD was daunting for the Egyptian mothers. Findings suggested that provision of inadequate education, healthcare and stigma constitute the main issues for mothers. Furthermore, ASD impacted negatively on the social life, emotional wellbeing and sacrifices of mothers of children with ASD. The findings provided valuable insight into the life of mothers, revealing what life really is like for mothers caring for a child with ASD in one of the low-medium-income countries. Understanding the mothers’ experiences of caring for children with ASD is crucial in providing support and developing the services that are urgently needed in Egypt.

Prevalence of Congenital Ocular Anomalies among Children with Genetic Disorders: An Egyptian Study

ABSTRACTPurpose: To assess the pattern and frequency of occurrence of ocular anomalies among other genetic disorders in Egypt. Methods: This is a cross-sectional study of 2500 cases presenting with genetic disorders. Cases were recruited from the clinical genetics department of the National Research Centre (NRC) over a four-year period between January 2011 and December 2014. Ophthalmological examination of the cases was performed in the pediatric ophthalmology department of Cairo University Hospitals. Results: Out of 2500 cases with congenital disorders, 2.4% suffered one or more ocular anomalies with a male to female ratio of 1.7:1. Consanguinity was reported in 76.7% and family history was positive in 35% of ocular cases. The most common ocular anomalies were congenital cataract, retinal dystrophies, glaucoma, and retinoblastoma in order of frequency. Chromosomal aberrations were detected in two retinoblastoma cases and in one case of charge association with cataract and iris coloboma. A truncating mutation in exon 8 of OCRL1 was reported in a case of Lowe syndrome with cataract. A total of 51.7% of ocular cases were non-isolated (associated with other genetic disorders). Conclusion: In Egypt, ocular genetic disorders are not uncommon among other genetic disorders. Consanguinity is high, suggesting high incidence of autosomal recessive inheritance of genetic disorders with an ocular component. Proper systemic assessment of all cases with ocular anomalies is a necessity due to the high percentage of non-isolated ocular anomalies. Genetic counseling of parents would help in reducing recurrence rates through prenatal diagnosis whenever possible.

Mental health care in Egypt: Review of current state, policy, and needs

ABSTRACTThis study aims to analyze the new Egyptian mental health law from a rights perspective in order to measure its compatibility with established human rights principles and the international standards that guide the practice of the mental health care. At the same time, the study considers the status of psychiatric care and basic mental health services for people with mental disorders in Egypt after several recent national upheavals along with the national prevalence of psychiatric disorders in the country. It will address the needs and the challenges facing current practice, with a discussion of some suggestions for improvements. Relevant data bases were searched (Medline, PubMed, and Cochrane library of systemic reviews and clinical trials) with the following Mesh terms: “mental disorders,” “substance-related disorders,” “Egyptian Mental Health systems,” and “Egyptian Mental health laws.” Articles published since 2000 were prioritized. In the latest years, a considerable gap between mental healthcare needs and available services in Egypt has been documented. There is comprehensive mental health legislation to enforce the rights of persons with mental disorders; but there is a lack of firm policy for implementation of interventions. The transformation of hospital-based to community-based mental health and the building of accessible services are necessary. Egypt urgently needs a national assessment of the deficiencies of its mental health system. The assessment would provide evidence and reliable information on existing needs and the barriers to accessing mental health care. The outputs of such an assessment will be helpful in finding locally and culturally sensitive solutions to reduce the mental health gap and can then be used in lobbying public opinion to rectify these conditions.

Skin Disorders in Egyptian Children with β-Thalassemia Major.

Thalassemia major is one of the common genetic disorders in Egypt. Skin disorders are usually neglected and frequently underdiagnosed among these patients. This work aimed to study the frequency and pattern of skin manifestations in Egyptian children with β-thalassemia. Fifty-four β-thalassemia major patients being followed at the Hematology Clinic of Beni-Suef University Hospital were selected to participate in this study. All patients underwent detailed history evaluation, clinical examination and laboratory investigations, including complete blood count and serum ferritin. All patients were examined by a dermatologist to record any skin disorders. Pruritus (37%), scars (33.3%), hyperpigmentation (31.5%) and xerosis (22.2%) were the most common findings. We found significant relations between serum ferritin and the occurrence of scars, hyperpigmentation, xerosis and ephelides (p<0.05). Also, significant associations between use of deferoxamine and scars (p=0.004), hyperpigmentation (p=0.004), xerosis (p=0.03) and ephelides (p=0.042) were found. Skin disorders are frequent in Egyptian children with thalassemia major. Careful skin examination is required to provide early diagnosis.