Disaster health education framework for short and intermediate training in Saudi Arabia: A scoping review.

Background: Saudi Arabia has made extensive efforts to manage disasters using unique national approaches; however, challenges and obstacles concerning disaster health handling persist. The nation has a reactive strategy to disaster management with a need for increased involvement of health professionals in disaster management and improvement of healthcare facilities emergency preparedness including competency-based education training. Objective: A comprehensive and consistent approach of disaster education programs for short and intermediate training of health professionals involved in disaster responses in Saudi Arabia is still not evident. Therefore, it is vital to explore and map the current state of the disaster education framework in Saudi Arabia. Methods: The Joanna Briggs Institute approach for scoping reviews was used to assess research articles and preprints between January 2000 and September 2021 from Saudi Digital Library; PubMed, CINAHL, and Google Scholar. Five experts identified key aspects of the disaster education approach and eligibility criteria to facilitate identification of relevant articles. Results: Only five articles met the specified criteria and described two short and three intermediate courses on disaster health management in Saudi Arabia. All courses involved competency-specific training aimed at basic or foundational level and involved a range of activities and learning types. None had refresher courses within 12 months. Conclusion: The review highlights the obvious scarcity of short and intermediate term evidence-based disaster health programs in Saudi Arabia. Adoption of the education framework proposed by the authors based on international frameworks could improve the quality and consistency of the disaster education curriculum in Saudi Arabia.

Primary Care as Primary Target: A Review of Terrorist Attacks Against Primary Care Providers and Their Offices.

BACKGROUND: Violence against primary care providers (PCPs) has increased during the current pandemic. While some of these violent acts are not defined as terrorist events, they are intentional events with an aim to disrupt, kill, or injure. Despite their pivotal role in health care, little is known about the risk for PCPs as targets of terrorism. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all terrorist attacks against PCPs and their offices from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary attack and weapon type, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 29 terrorist attacks against PCPs and their offices from 1970-2019. The majority of attacks occurred during or after 2010. There were 58 fatalities, 52 injured, and 13 hostages. Most documented attacks took place in Pakistan, the United States, and Sri Lanka. Bombings concerned 55% of cases and 21% were hostage-takings. CONCLUSION: Although less common than attacks on other health care related targets, terrorist attacks against PCPs have occurred. The majority of attacks occurred during the last decade. Future studies are warranted to further assess the risk of terrorist attacks against PCPs: before, during, and beyond the current pandemic.

Are Dutch Hospitals Prepared for Chemical, Biological, or Radionuclear Incidents? A Survey Study.

Introduction Being one of Europe's most densely populated countries, and having multiple nuclear installations, a heavy petrochemical industry, and terrorist targets, the Netherlands is at-risk for chemical, biological, or radionuclear (CBRN) incidents. Recent world and continental events show that this threat is real and that authorities may be underprepared. Hypothesis The hypothesis of this study is that Dutch hospitals are underprepared to deal with these incidents. METHODS: A descriptive, cross-sectional study was performed. All 93 Dutch hospitals with an emergency department (ED) were sent a link to an online survey on different aspects of CBRN preparedness. Besides specific hospital information, information was obtained on the hospital's disaster planning; risk perception; and availability of decontamination units, personal protective equipment (PPE), antidotes, radiation detection, infectiologists, isolation measures, and staff training. RESULTS: Response rate was 67%. Sixty-two percent of participating hospitals were estimated to be at-risk for CBRN incidents. Only 40% had decontamination facilities and 32% had appropriate PPE available for triage and decontamination teams. Atropine was available in high doses in all hospitals, but specific antidotes that could be used for treating victims of CBRN incidents, such as hydroxycobolamine, thiosulphate, Prussian blue, Diethylenetriaminepentaacetic acid (DTPA), or pralidoxime, were less frequently available (74%, 65%, 18%, 14%, and 42%, respectively). Six percent of hospitals had radioactive detection equipment with an alarm function and 22.5% had a nuclear specialist available 24/7 in case of disasters. Infectiologists were continuously available in 60% of the hospitals. Collective isolation facilities were present in 15% of the hospitals. CONCLUSION: There is a serious lack of hospital preparedness for CBRN incidents in The Netherlands. Mortelmans LJM , Gaakeer MI , Dieltiens G , Anseeuw K , Sabbe MB . Are Dutch hospitals prepared for chemical, biological, or radionuclear incidents? A survey study. Prehosp Disaster Med. 2017;32(5):483-491.

Are Tertiary Care Paediatricians Prepared for Disaster Situations?

INTRODUCTION: Children, with their specific vulnerabilities and needs, make up to more than 20% of society, so they are at risk of getting involved in disasters. Are the specialists treating them for medical problems in daily life also capable to deal with them in disaster situations? HYPOTHESIS/PROBLEM: The goals of this study were to evaluate perceived knowledge and capability of tertiary pediatricians to deal with disasters, to identify promoting factors, and to evaluate education need and willingness to work. METHODS: A survey looking for demographics, hospital disaster planning, estimated risk and capability for disasters, training, and willingness to work, and a set of six content assessment questions to evaluate knowledge, were presented to emergency pediatricians and pediatric emergency physicians in specialized tertiary centers. RESULTS: The response rate was 51%. Thirty-five percent had disaster training and 53% felt that disaster education should be obligatory in their curriculum. Risk for disasters was estimated from 2.4/10 for nuclear incidents to 7.6/10 for major trauma. Self-estimated capability for these situations ranged from 1.8/10 in nuclear incidents to 7.6/10 in major trauma. Unconditional willingness to work ranged from 37% in nuclear situations to 68% in pandemics. Mean score on the questions was 2.06/6. Training, knowledge of antidote and personal protective equipment (PPE) use, self-estimated capability, and exposure were significant predictors for higher scores. Willingness to work correlated significantly with age, self-estimated capability, and risk estimation. In case of chemical and nuclear incidents, there was correlation with knowledge on the use of decontamination, PPE, and radio-detection devices. CONCLUSION: Despite a clear perception of the risks and a high willingness to work, preparedness is limited. The major conclusion is that basics of disaster management should be included in pediatric training.

Are Belgian military students in medical sciences better educated in disaster medicine than their civilian colleagues?

INTRODUCTION: Historically, medical students have been deployed to care for disaster victims but may not have been properly educated to do so. A previous evaluation of senior civilian medical students in Belgium revealed that they are woefully unprepared. Based on the nature of their military training, we hypothesised that military medical students were better educated and prepared than their civilian counterparts for disasters. We evaluated the impact of military training on disaster education in medical science students. METHODS: Students completed an online survey on disaster medicine, training, and knowledge, tested using a mixed set of 10 theoretical and practical questions. The results were compared with those of a similar evaluation of senior civilian medical students. RESULTS: The response rate was 77.5%, mean age 23 years and 59% were males. Overall, 95% of military medical students received some chemical, biological, radiological and nuclear training and 22% took part in other disaster management training; 44% perceived it is absolutely necessary that disaster management should be incorporated into the regular curriculum. Self-estimated knowledge ranged from 3.75 on biological incidents to 4.55 on influenza pandemics, based on a 10-point scale. Intention to respond in case of an incident ranged from 7 in biological incidents to 7.25 in chemical incidents. The mean test score was 5.52; scores improved with educational level attained. A comparison of survey data from civilian senior medical master students revealed that, except for influenza pandemic, military students scored higher on knowledge and capability, even though only 27% of them were senior master students. Data on willingness to work are comparable between the two groups. Results of the question/case set were significantly better for the military students. CONCLUSIONS: The military background and training of these students makes them better prepared for disaster situations than their civilian counterparts.

Dutch senior medical students and disaster medicine: a national survey.

BACKGROUND: Medical students have been deployed in victim care of several disasters throughout history. They are corner stones in first-line care in recent pandemic planning. Furthermore, every physician and senior medical student is expected to assist in case of disaster situations, but are they educated to do so? Being one of Europe's densest populated countries with multiple nuclear installations, a large petrochemical industry and also at risk for terrorist attacks, The Netherlands bear some risks for incidents. We evaluated the knowledge on Disaster Medicine in the Dutch medical curriculum. Our hypothesis is that Dutch senior medical students are not prepared at all. METHODS: Senior Dutch medical students were invited through their faculty to complete an online survey on Disaster Medicine, training and knowledge. This reported knowledge was tested by a mixed set of 10 theoretical and practical questions. RESULTS: With a mean age of 25.5 years and 60 % females, 999 participants completed the survey. Of the participants, 51 % considered that Disaster Medicine should absolutely be taught in the regular medical curriculum and only 2 % felt it as useless; 13 % stated to have some knowledge on disaster medicine. Self-estimated capability to deal with various disaster situations varied from 1.47/10 in nuclear incidents to 3.92/10 in influenza pandemics. Self-estimated knowledge on these incidents is in the same line (1.71/10 for nuclear incidents and 4.27/10 in pandemics). Despite this limited knowledge and confidence, there is a high willingness to respond (ranging from 4.31/10 in Ebola outbreak over 5.21/10 in nuclear incidents to 7.54/10 in pandemics). The case/theoretical mix gave a mean score of 3.71/10 and raised some food for thought. Although a positive attitude, 48 % will place contaminated walking wounded in a waiting room and 53 % would use iodine tablets as first step in nuclear decontamination. Of the participants, 52 % even believes that these tablets protect against external radiation, 41 % thinks that these tablets limit radiation effects more than shielding and 57 % believes that decontamination of chemical victims consists of a specific antidote spray in military cabins. CONCLUSIONS: Despite a high willingness to respond, our students are not educated for disaster situations.

Preparedness of Belgian civil hospitals for chemical, biological, radiation, and nuclear incidents: are we there yet?

OBJECTIVE: As one of Europe's most densely populated countries with multiple nuclear installations and a prominent petrochemical industry, Belgium is at some reasonable risk for terrorist attacks or accidental chemical, biological, radiation, and nuclear (CBRN) incidents. We hypothesize that local hospitals are not sufficiently prepared to deal with these incidents. MATERIALS AND METHODS: All 138 Belgian hospitals with an emergency department (ED) were sent a survey on their preparedness. Data on hospital disaster planning, risk perception, availability of decontamination units, personal protective equipment, antidotes, radiation detection, infectiologists, isolation measures, and staff training were collected. RESULTS: The response rate was 72%. Although 71% of hospitals reported being at risk for CBRN incidents, only 53% planned for the same in their disaster plans. Only 11% of hospitals had decontamination facilities in front of or at the ED entrance and only 6% had appropriate personal protective equipment for triage and decontaminating teams. Atropine was available at all centers, but more specific antidotes such as hydroxycobolamine, thiosulphate, or pralidoxime were less available (47, 47, and 19%, respectively). Six percent of hospitals had radiodetection equipment with an alarm function and 14% had a nuclear specialist available 24/7. Infectiologists were continuously available in 26% of the total EDs surveyed. Individual isolation facilities were present in 36% of the EDs, and isolation facilities capable of housing larger groups were present in 9%. University hospitals were significantly better prepared than community hospitals. CONCLUSION: There are serious gaps in hospital preparedness for CBRN incidents in Belgium. Lack of financial resources is a major obstacle in achieving sufficient preparedness.

Mass carbon monoxide poisoning at an ice-hockey game: initial approach and long-term follow-up.

OBJECTIVES: A mass carbon monoxide (CO) intoxication during an ice-hockey game is described. Two hundred and thirty-five patients were seen in different hospitals, 88 of them the same night at the nearby emergency department. To evaluate long-term implications and to identify relevant indicators, a follow-up study was organized 1 year after the incident. METHODS: Apart from the file data from the emergency departments, a 1-year follow-up mailing was sent to all patients. RESULTS: One hundred and ninety-one patients returned their questionnaire (86%). The mean age of the patients was 28 years, with 61% men. The mean carboxyhaemoglobin (COHb) was 9.9%. COHb levels were significantly higher for individuals on the ice (referee, players and maintenance personnel). There was a significant relationship with the initial presence of dizziness, fatigue and the COHb level. Headache, abdominal pain, nausea and vomiting were not significantly related to the COHb levels. The relationship between symptoms and CO level, however, should be interpreted with caution as there was a wide range between exposure and blood tests. 5.2% of patients had residual complaints, all including headache, with a significant higher incidence with high COHb levels. Only two patients had an abnormal neurological control (one slightly disturbed electroencephalography and one persistent encephalopathic complaint). Work incapacity was also significantly related to COHb levels. CONCLUSION: CO mass poisonings remain a risk in indoor sporting events. Although it causes an acute mass casualty incident, it is limited in time and delayed problems are scarce. Symptomatology is a poor tool for triage. The best prevention is the use of nonmineral energy sources such as for example electricity.

Patients' and relatives' view on witnessed resuscitation in the emergency department: a prospective study.

BACKGROUND: The appropriateness of family witnessing resuscitation (FWR) is an ethical dilemma with most emergency care providers being opponents. We hypothesized that patients and their families prefer to witness resuscitation of their loved ones. METHODS: One hundred and fifty patients treated for potential life-threatening conditions in our emergency department were presented with a survey on FWR in the reconvalescence phase. They were asked to give their opinion supposing their situation had worsened, requiring a resuscitation effort. Their closest relatives were asked to complete a related questionnaire. RESULTS: Mean age was 67 years (patient group) and 55 years (relatives group). Fifty-eight percent of the patients were males with only 33% males in the relatives group. Seventy-two percent of the patients preferred the presence of a relative during resuscitation, although 35% estimate that this could be quite a traumatic experience. Forty-one percent had a history of serious medical problems. In the relatives group, 75% expressed their wish to stay with their loved ones and 49% did not fear that this would be too traumatic. There was a good match in patient and family attitude towards FWR (P<0.001). Relatives of a patient with a serious medical history were significantly more in favour of FWR (P<0.01). CONCLUSION: Our study showed that patients and relatives preferred family presence in emergency department during resuscitation, even when the fear of traumatic effects is considered. It will be a great challenge training emergency care providers for this situation. Staff shortages might compromise the essential support of family members in such situations.

Should relatives witness resuscitation in the emergency department? The point of view of the Belgian Emergency Department staff.

OBJECTIVE: To assess the opinion of Belgian Emergency Department (ED) staff regarding family-witnessed resuscitation (FWR). METHODS: All 142 Belgian EDs were sent a questionnaire on hospital-related data and personal questionnaires for the ED staff concerning their opinion on FWR. Opinions of physicians, nurses and other emergency care providers were compared and related with hospital or sociodemographic data. RESULTS: Eighty-five ED services (60%) responded with a total of 1143 personal questionnaires: of these 79% were nurses, and 19% physicians. Eighty percent of the hospitals had a prehospital intervention team. Only two departments (2.5%) practiced structured FWR; 21% put the relatives in the corridor. Eleven percent did not give any information at all to relatives. Fourteen percent organized 'training in coping with relatives'. Forty-one percent of the staff members had been asked for FWR but only 33% were positive about it. Fifty-six percent thought that relatives could be of use in the shock room. Sixty-six percent experienced it as a burden. Sixty-five percent thought that FWR helps in grieving but 93% feared traumatic distress. Sixty-four percent would like to attend the resuscitation of their own relatives. Thirty-five percent fear a high risk of complaints. Prehospital experience, higher workload, seniority and male staff are significant advantages towards FWR. Emergency physicians are more positive towards FWR, nurses less so, followed by other physicians. CONCLUSION: The Belgian ED staff is still unconvinced about FWR. Despite evidence-based data they still think that resuscitation is traumatizing for relatives. Experience, both in as well as out of hospital, is a positive factor.

Axis or Harris ring in odontoid fractures, old fashioned but not obsolete.

Clearing the cervical spine after blunt trauma remains a challenge. Even in the computed tomography era many emergency departments worldwide still use classical X-rays in first evaluation. Low odontoid fractures are frequently missed, especially in unconscious patients where an open mouth view is not available. Evaluation of the Harris ring in the lateral view can improve identification rate. We studied the diagnostic values of this sign and the educational effect on trainees. Lateral views of 12 computed tomography confirmed low-axis fractures and 13 controls were randomly presented to 17 residents (traumatology, neurosurgery and emergency medicine) and five experienced radiologists. After the residents were taught the use of the axis ring, they had to review the set. Diagnosis was scored with a degree of certitude from 5 to 1. The specificity and sensitivity for the radiologists was 88% (confidence interval 80-96) and 82% (confidence interval 72-91), respectively. The effect of the education on the scores of the residents was evaluated using the Wilcoxon ranking test with a significant effect for the traumatologists (P=0.0008), emergency physicians (P=0.0005) as well for the neurosurgeons (P=0.0087). The axis ring can be a useful diagnostic tool in identifying low odontoid fractures on cross-table cervical spine X-rays. It is easy to teach and should be included in X-ray-based C-spine clearing protocols.

Impact of lightning strikes on hospital functions.

Two regional hospitals were struck by lightning during a one-month period. The first hospital, which had 236 beds, suffered a direct strike to the building. This resulted in a direct spread of the power peak and temporary failure of the standard power supply. The principle problems, after restoring standard power supply, were with the fire alarm system and peripheral network connections in the digital radiology systems. No direct impact on the hardware could be found. Restarting the servers resolved all problems. The second hospital, which had 436 beds, had a lightning strike on the premises and mainly experienced problems due to induction. All affected installations had a cable connection from outside in one way or another. The power supplies never were endangered. The main problem was the failure of different communication systems (telephone, radio, intercom, fire alarm system). Also, the electronic entrance control went out. During the days after the lightening strike, multiple software problems became apparent, as well as failures of the network connections controlling the technical support systems. There are very few ways to prepare for induction problems. The use of fiber-optic networks can limit damage. To the knowledge of the authors, these are the first cases of lightning striking hospitals in medical literature.

Are Belgian senior medical students ready to deliver basic medical care in case of a H5N1 pandemic?

Medical care systems will be overwhelmed if a human H5N1 pandemic should occur. Several national disaster plans, including that of Belgium, focus on maximal treatment at home with senior medical students supporting frontline care. To evaluate the knowledge and preparedness of Belgian senior medical students, an e-mail survey of senior medical students (last two years of education) attending Flemish universities was conducted. A total of 243 students (30%) replied. Only 21.8% of them were aware of the possibility of being involved in this planning. A total of 77.4% estimated H5N1 to be a possible threat to national health. Seventy percent of respondents reacted positively towards the idea of being involved in implementing primary care, and only 9.5% were absolutely opposed to the idea. A total of 82.3% would care for pandemic patients if necessary, but only 41.2% would do so if these patients were children. Only 18.9% estimated themselves to be sufficiently educated regarding H5N1. Ninety-one percent were convinced that care for H5N1-influenza patients should be incorporated into their regular curriculum. Several antiviral products were reported by the students to be efficient for treating H5N1, but only 34.6% correctly chose oseltamavir and/or zanamavir and 35.4% replied "I don't know". A total of 95.5% correctly answered that the regular influenza vaccination doesn't protect against H5N1. The risk for human-to-human transmission was rated to be small by 50.6% (none 21%, high 27.6%). The human infection risk was rated to be small by 74.1% (none 1.6%, high 23%). There is a high level of willingness to participate among senior medical students. However, in the case of pediatric patients they're more reserved. It would be useful to incorporate a focused session on preparedness in the regular teaching program. A legal base for their actions should also be provided. Ethical guidelines on rights and duties in case of a pandemic should be prepared by an international, multidisciplinary group of experts.

Seizures and hyponatremia after excessive intake of diet coke.

We describe a case of epileptic seizures after a massive intake of diet coke. Apart from the hyponatremia due to water intoxication the convulsions can be potentiated by the high dose of caffeine and aspartame from the diet coke. To our knowledge this is the first report of seizures due to excessive diet coke intake.

Differential diagnosis between viral and bacterial meningitis in children.

OBJECTIVE: The differential diagnosis between viral meningitis and bacterial meningitis is often very difficult. The results of peripheral blood and spinal fluid analysis are not 100% accurate. We tried to find a useful 'bedside' decision-making tool, based on laboratory results readily available at the emergency department. METHODS: Retrospective study design. Analysis of a consecutive series of all children (age 0-15 years) admitted to the paediatric ward because of a viral or bacterial meningitis, in the period from 1997 to September 2005. RESULTS: Seventy-one children with viral and 21 with bacterial meningitis were included. Bacterial meningitis occurred at much younger ages than viral meningitis. The paediatrician decided to administer antibiotics in 41 of 71 children with viral meningitis and in all children with bacterial meningitis. We developed a 'bacterial meningitis score' based on C-reactive protein in peripheral blood, as well as glucose and protein in cerebrospinal fluid. Using this score, we could distinguish 54 of 71 patients with viral meningitis from the group with bacterial meningitis. When the dispensing of antibiotics was based on this score, only 16 patients with viral meningitis would receive antibiotics. CONCLUSION: We present a bedside bacterial meningitis score. Using this bacterial meningitis score as a decision-making tool, we would be able to avoid antibiotics in a large number of children with viral meningitis. As this gives a 100% success rate, thus guaranteeing that bacterial meningitis patients would receive the proper therapy, our bacterial meningitis score could be an accurate decision-support tool.

Improving tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study.

BACKGROUND: The choice of tetanus prophylaxis for patients with wounds depends on obtaining their vaccination history, which has been demonstrated to be unreliable. Use of a rapid immunoassay (Tétanos Quick Stick, the TQS), combined with knowledge of certain demographic characteristics, may improve the evaluation of tetanus immunity and thus help to avoid inadequate prophylactic measures and reduce costs. OBJECTIVES: To evaluate the contribution of the TQS in the choice of tetanus prophylaxis and to perform a cost-effectiveness analysis. The final aim was to define the place of the TQS in a modified algorithm for assessment of tetanus immunity in the emergency department. METHOD: In this Belgian prospective, double-blind, multicentre study, 611 adult patients with a wound were included; 498 (81.5%) records were valid. The TQS test was performed by a nurse before the vaccination history was taken and the choice of prophylaxis was made, using the official algorithm (Belgian Superior Health Council), by a doctor who was unaware of the TQS result. RESULTS: The prevalence of protective anti-tetanus immunity was 74.1%. Immunity was lower in older patients and in female patients. The TQS was a cost-effective tool for patients presenting with a tetanus-prone wound and considered from the vaccination history to be unprotected. Use of the TQS would have improved management in 56.9% (95% CI 47.7% to 65.7%) of patients by avoiding unnecessary treatments, leading to a reduction in the mean cost per patient (10.58 euros/patient with the TQS versus 11.34 euros/patient without). The benefits of the TQS use were significantly greater in patients <61 years old: unnecessary treatment would have been avoided in 76.9% (95% CI 65.8% to 85.4%) of cases and the mean cost per patient reduced to 8.31 euros. CONCLUSION: In selected patients, the TQS is a cost-effective tool to evaluate tetanus immunity. An algorithm is proposed for ED assessment of tetanus immunity integrating age and the TQS result.

Are Belgian hospitals prepared for an H5N1-pandemic?

OBJECTIVE: Virulent airborne diseases can be a real burden to a nation's health system. The most recent threat is the fear of a mutation-induced H5N1-influenza pandemic. We studied whether Belgian hospitals are able to deal with H5N1-influenza infected patients in the case of a pandemic. Many patients, including children, may require artificial ventilation within 48 h after admission. METHODS: A survey aimed at determining 'availability and preparedness' was sent by e-mail to the different Belgian Emergency Departments. RESULTS AND DISCUSSION: Sixty-five hospitals were finally included. The amount of patients being potentially admitted is limited, owing to the reduced number of intensive care beds equipped with automatic ventilators. Furthermore, the number of available intensive care beds for children is still lower than for adult patients. The number of mortuary places, in the case of a catastrophe, is also insufficient. Although most hospitals set up a disaster plan on H5N1, there are only limited stocks of antiviral medication to protect the hospital staff in the acute phase. A separate triage area is only available in a limited number of hospitals. We conclude that Belgian hospitals and emergency departments are not equipped to deal with potential pandemic situations.

Mountainbiker's hematuria: a case report.

Although exercise-induced hematuria is a well known finding in long distance running, it is extremely rare in cycling. We describe a case of gross atraumatic hematuria after mountainbiking. The only pathologic finding in our patient was a small hyperemic zone in the bladder mucosa suggesting a local traumatic origin due to repeated contact of the flaccid bladder wall against the bladder base. This in contrast with the renal origin commonly seen in marathon runners. It is a benign hematuria that usually resolves within a day without specific treatment. The best treatment is prevention by means of good bladder filling. Neoplasm of the urothelium should be ruled out in differential diagnosis.