Navigating Early and Late Hematomas in Cochlear Implantation: A Tri-Case Analysis.

Cochlear implantation is a safe, popular procedure for severe hearing loss in both children and adults. Complications are categorized as major and minor, with hematomas and seromas being minor. This article discusses advanced diagnosis and treatment for three patients with post-implantation hematomas (two early, one late).

Separating the Physician and Patient: A Paradigm Shift for Routine Otolaryngology Examinations in COVID-19-Like Aerosol-Contaminated Environments.

OBJECTIVE: To evaluate the attitudes of physicians and patients toward physical examination in physically separated environments using a laryngoscopic examination model. MATERIALS AND METHODS: Six experienced laryngologists performed laryngoscopic examinations in 30 patients in a closed-chamber examination unit. The physicians and patients were asked to compare all domains with their previous standard laryngoscopic examination experience using a 10-point visual analog scale (0, poor performance; 10, good performance), including effectiveness of communication, difficulty of examination, perception of safety against airborne transmission of COVID-19, applicability of the unit for future examinations, perception of protective environment, and overall comfort. RESULTS: All laryngoscopic examinations were performed successfully. Effectiveness of communication, difficulty of examination, perception of protective environment, and overall comfort did not differ between physicians and patients (P > .05 for all comparisons). However, both physicians and patients found the examination to be difficult. While physicians evaluated the system as safe against airborne transmission of COVID-19, patients were not confident that the system was safe (8.70 ± 1.93 vs 2.87 ± 2.37, respectively, P = .001). Physicians also gave a higher score to future applicability of the unit for examinations than patients (8.90 ± 1.42 vs 7.10 ± 2.62, respectively, P = .001). CONCLUSION: Physically separating the physician and patient is a feasible method of physical examination in aerosol-contaminated environments.

Optimizing Early Detection: Validating Obstructive Sleep Apnea-18 (OSA-18) in Turkish-Speaking Pediatric Patients.

Objective: Quality of life (QoL) assessments are increasingly important for evaluating the well-being of children with Obstructive Sleep Apnea Syndrome (OSAS). This study's objective is to culturally adapt and validate the Turkish version of the OSA-18 questionnaire, a commonly used tool for assessing QoL in children with OSAS. Methods: The OSA-18 questionnaire was translated and culturally adapted for use in the Turkish-speaking population. The study was conducted with 180 participants, 100 boys and 80 girls, with a mean age of 6.16±2.14 years. The participants were divided into two groups. The patient group comprised individuals with symptoms of OSAS based on clinical evaluation, including anamnesis, physical examination, and video recording of apnea and snoring. The patient group underwent adenotonsillectomy and their caregivers completed the Turkish version of the OSA-18 scale postoperatively. The control group comprised 90 children who were similar to the patient group in terms of gender and age. These children had no major complaints such as snoring, apnea, fatigue during the day, irritability, or distraction. In the physical examination of this group, no major tonsillar or adenoid hypertrophy, which causes significant stenosis in the upper airway, was observed. Internal consistency, reliability, validity, responsiveness, and factor analysis were assessed. Results: The Turkish version of the OSA-18 questionnaire demonstrated excellent reliability, with a Cronbach's alpha of 0.929. The test-retest results were not statistically different. Validity was confirmed through a positive correlation between the OSA-18 score and external parameters, such as the Mallampati score, and tonsil and adenoid size. We found a statistically significant reduction in OSA-18 scores postoperatively, signifying a robust responsiveness to the intervention. Conclusion: Our study confirms the suitability of the Turkish OSA-18 questionnaire for assessing the QoL in children with OSAS. This quick and easy-to-use tool will be valuable for future research on Turkish-speaking children with OSAS, aiding in the evaluation of pediatric OSAS and QoL.

Cochlear Implantation in Primrose Syndrome with a Novel ZBTB20 Gene Variant.

In this article, we aim to present details of the cochlear implantation procedure performed in a patient with Primrose syndrome, which is a rare genetic condition characterized by physical deformities, sensorineural hearing loss, and metabolic disorders. While its long-term prognosis is still under investigation, the absence of intraoperative and postoperative complications indicates promising findings. This designates cochlear implantation as a viable therapeutic approach for sensorineural hearing loss linked to Primrose syndrome. As cochlear implantation in cases with Primrose syndrome has not been discussed previously in the literature and our patient has recently been operated on, additional investigation is imperative to broaden the understanding of cochlear implant outcomes in this patient population.

Betahistine add-on therapy for treatment of subjects with posterior benign paroxysmal positional vertigo: a randomized controlled trial / Terapia adjuvante de betaistina para o tratamento de indivíduos com vertigem posicional paroxística benigna posterior: um ensaio clínico randomizado

Abstract Introduction Benign paroxysmal positional vertigo is a common vestibular disorder that accounts for one fifth of hospital admissions due to vertigo, although it is commonly undiagnosed. Objective To evaluate the effects of betahistine add-on therapy in the treatment of subjects with posterior benign paroxysmal positional vertigo. Methods This randomized controlled study was conducted in a population of 100 subjects with posterior benign paroxysmal positional vertigo. Subjects were divided into the Epley maneuver + betahistine group (group A) and Epley maneuver only (group B) group. Subjects were evaluated before and 1-week after the maneuver using a visual analog scale and dizziness handicap inventory Results One hundred subjects completed the study protocol. The Epley maneuver had an overall success rate of 95% (96% in group A; 94% in group B, p= 0.024). Groups A and B had similar baseline visual analog scale scores (6.98 ± 2.133 and 6.27 ± 2.148, respectively, p= 0.100). After treatment, the visual analog scale score was significantly lower in both groups, and was significantly lower in group A than group B (0.74 ± 0.853 vs. 1.92 ± 1.288, respectively, p= 0.000). The change in visual analog scale score after treatment compared to baseline was also significantly greater in group A than group B (6.24 ± 2.01 vs. 4.34 ± 2.32, respectively, p= 0.000). The baseline dizziness handicap inventory values were also similar in groups A and B (55.60 ± 22.732 vs. 45.59 ± 17.049, respectively, p= 0.028). After treatment, they were significantly lower in both groups. The change in score after treatment compared to baseline was also significantly greater in group A than group B (52.44 ± 21.42 vs. 35.71 ± 13.51, respectively, p= 0.000). Conclusion The Epley maneuver is effective for treatment of benign paroxysmal positional vertigo. Betahistine add-on treatment in posterior benign paroxysmal positional vertigo resulted in improvements in both visual analog scale score and dizziness handicap inventory.

Resumo Introdução A vertigem posicional paroxística benigna é um distúrbio vestibular comum, responsável por um quinto das internações hospitalares por vertigem, embora seja comumente não diagnosticada. Objetivo Avaliar os efeitos da terapia adjuvante com betaistina no tratamento de indivíduos com vertigem posicional paroxística benigna posterior. Método Este estudo randomizado controlado foi feito em uma população de 100 indivíduos com vertigem posicional paroxística benigna posterior. Os indivíduos foram divididos nos grupos: manobra de Epley + betaistina (grupo A) e manobra de Epley apenas (grupo B). Os indivíduos foram avaliados antes e uma semana após a manobra por meio da escala visual analógica EVA e do questionário dizziness handicap inventory. Resultados Cem indivíduos completaram o protocolo do estudo. A manobra de Epley demonstrou uma taxa de sucesso global de 95% (96% no grupo A; 94% no grupo B, p = 0,024). Os grupos A e B tiveram escores basais semelhantes na EVA (6,98 ± 2,133 e 6,27 ± 2,148, respectivamente, p = 0,100). Após o tratamento, o escore na EVA foi significantemente menor em ambos os grupos e foi menor no grupo A do que no grupo B (0,74 ± 0,853 vs. 1,92 ± 1,288, respectivamente, p = 0,000). A mudança no escore da EVA após o tratamento em comparação com a linha basal também foi significativamente maior no grupo A do que no grupo B (6,24 ± 2,01 vs. 4,34 ± 2,32, respectivamente, p = 0,000). Os valores basais no dizziness handicap inventory também foram semelhantes nos grupos A e B (55,60 ± 22,732 vs. 45,59 ± 17,049, respectivamente, p = 0,028). Após o tratamento, eles foram significantemente menores em ambos os grupos. A mudança no escore após o tratamento em comparação com a linha basal também foi significantemente maior no grupo A do que no grupo B (52,44 ± 21,42 vs. 35,71 ± 13,51, respectivamente, p = 0,000). Conclusão A manobra de Epley é eficaz no tratamento da vertigem posicional paroxística benigna. O tratamento complementar com betaistina na vertigem posicional paroxística benigna posterior resultou em melhoria tanto no escore da EVA quanto no do dizziness handicap inventory.

A Rare Sinonasal Malignancy: Biphenotypic Sinonasal Sarcoma.

Biphenotypic sinonasal sarcoma (BSNS), which has been described in the recent years, is a low-grade spindle cell sinonasal sarcoma characterized by rare neural and myogenic features. It has a slow growth pattern; does not metastasize, but local recurrences are common after surgery. Non-specificity of examination findings and symptoms and similarities of its histopathological features with other spindle cell sarcomas, neural tumors, and skeletal muscle-derived tumors involving the nasal cavity make the diagnosis difficult. Therefore, histopathological features should be evaluated together with immunophenotyping and molecular studies for differential diagnosis. There are very few BSNS cases or case series in the literature. In this report, we reported our clinical approach to a case with BSNS in the right nasal cavity and the histopathological features of the disease in the light of the current literature.

Betahistine add-on therapy for treatment of subjects with posterior benign paroxysmal positional vertigo: a randomized controlled trial.

INTRODUCTION: Benign paroxysmal positional vertigo is a common vestibular disorder that accounts for one fifth of hospital admissions due to vertigo, although it is commonly undiagnosed. OBJECTIVE: To evaluate the effects of betahistine add-on therapy in the treatment of subjects with posterior benign paroxysmal positional vertigo. METHODS: This randomized controlled study was conducted in a population of 100 subjects with posterior benign paroxysmal positional vertigo. Subjects were divided into the Epley maneuver + betahistine group (group A) and Epley maneuver only (group B) group. Subjects were evaluated before and 1-week after the maneuver using a visual analog scale and dizziness handicap inventory RESULTS: One hundred subjects completed the study protocol. The Epley maneuver had an overall success rate of 95% (96% in group A; 94% in group B, p =  0.024). Groups A and B had similar baseline visual analog scale scores (6.98 ±â€¯2.133 and 6.27 ±â€¯2.148, respectively, p = 0.100). After treatment, the visual analog scale score was significantly lower in both groups, and was significantly lower in group A than group B (0.74 ±â€¯0.853 vs. 1.92 ±â€¯1.288, respectively, p = 0.000). The change in visual analog scale score after treatment compared to baseline was also significantly greater in group A than group B (6.24 ±â€¯2.01 vs. 4.34 ±â€¯2.32, respectively, p = 0.000). The baseline dizziness handicap inventory values were also similar in groups A and B (55.60 ±â€¯22.732 vs. 45.59 ±â€¯17.049, respectively, p = 0.028). After treatment, they were significantly lower in both groups. The change in score after treatment compared to baseline was also significantly greater in group A than group B (52.44 ±â€¯21.42 vs. 35.71 ±â€¯13.51, respectively, p = 0.000). CONCLUSION: The Epley maneuver is effective for treatment of benign paroxysmal positional vertigo. Betahistine add-on treatment in posterior benign paroxysmal positional vertigo resulted in improvements in both visual analog scale score and dizziness handicap inventory.

Turkish Guideline for Diagnosis and Treatment of Allergic Rhinitis (ART).

OBJECT: To prepare a national guideline for Otorhinolaryngologist who treat allergic rhinitis patients. METHODS: The study was conducted by three authors, namely the writing support team. The support team made the study plan, determined the writing instructions, chose the subgroups including the advisory committee, the advisors for authors and the authors. A workshop was organized at the very beginning to explain the details of the study to the team. Advisors took the chance to meet their coworkers in their subgroups and determined the main headings and subheadings of the guideline, together with the authors. After key words were determined by the authors, literature search was done in various databases. The authors keep in touch with the advisors and the advisors with the advisory committee and the support group at every stage of the study. National and International published articles as well as the abstracts of unpublished studies, imperatively presented in National Congresses, were included in this guideline. Only Guideline and meta-analyses published in last seven years (2013-2017) and randomized controlled studies published in last two years (2015-2017) were included. After all work was completed by the subgroups, support team brought all work together and edited the article. RESULTS: A detailed guideline about all aspects of allergic rhinitis was created. CONCLUSION: The authors believe that this guideline will enable a compact and up-to-date information on allergic rhinitis to healthcare professionals. This guideline is the first in the field of Otolaryngology in Turkey. It should be updated at regular intervals.

Incidence and Management of Delayed Epistaxis Following Endoscopic Skull Base Surgery.

OBJECTIVE: Among other complications of endoscopic skull base surgery, delayed epistaxis has not been given much importance. This report presents postoperative delayed nosebleed cases in a large number of patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of lesions. METHODS: Three hundred and sixty three patients who were reached to the sellar region by endoscopic endonasal transsphenoidal route and operated was included in the study. Retrospective chart reviewing of these patients was performed. The correlation between the duration of nosebleeds, bleeding location, treatment methods and comorbidities of the patients were evaluated. RESULTS: Ten patients (3.6%) reported delayed epistaxis in the postoperative period and were referred to the otolaryngology department. Postoperative epistaxis occurred between days 7th and 33th (mean 16.5) days. The treatment consisted of chemical silver nitrate cauterization in two patients, return to the operating room in three patients, nasal packing in five patients. CONCLUSION: Delayed postoperative epistaxis often has no obvious etiology, and intervention requires teamworking. Well-coordinated teamworking of the neurosurgeon with other specialities such as neuroradiology and otorhinolaryngology is needed to achieve better results.

Nasal Septal Hematoma and Abscess in Children: An Uncommon Otorhinolaryngology Emergency Revisited.

OBJECTIVE: To evaluate the demographic factors, trauma type, treatment, and long-term results in patients with nasal septal hematoma (NSH) and nasal septal abscess (NSA) in pediatric age group. METHODS: Between the years 2006 and 2019, patients who received a diagnosis of NSA and NSH were included for the study. Demographic data, the surgical findings, and long-term follow-up results were recorded. RESULTS: A total of 68 patients were identified. Forty-five patients were diagnosed as NSA and 23 patients were diagnosed with NSA. Mean age of the patients was 7.00 ±â€Š3.33 years. Patients did not differ in terms of age, gender, and etiology. Mean duration of the symptoms was significantly high in NSA group (4.11 ±â€Š4.00 days for NSH and 7.61 ±â€Š7.71 days for NSA, P = 0.011). Associated nasal fracture was significantly high in NSH group. Previous nasal examination was significantly high in NSA group. Epistaxis was present significantly high in NSH group (P = 0.013). Fever and purulent nasal discharge was observed significantly high in NSA group. Forty-seven (n = 47) patients can be reevaluated for long-term deformity (NSH, n = 34 [72.34%] and NSA, n = 13 [27.65%]). Mean follow-up period of the patients was 8.7 years. In total, 61.7% of the patients experienced minor or major sequelae. Both NSA and NSH groups did not differ in terms of minor sequelae and major sequelae. No sequleae was significantly high in NSH group (for NSH n = 17/34-(50,0%); for NSA n = 1/13- (7,7%), p = 0.008). Both NSA and NSH groups did not differ in terms of no sequelae and minor sequelae. CONCLUSION: The NSH and NSA are uncommon conditions that needed prompt diagnosis and intervention.

Evaluation of the Presence of Sensorineural Hearing Loss and the Relationship With Intraoperative Findings in Cholesteatoma.

We investigated whether cholesteatoma is associated with sensorineural hearing loss (SNHL) and the effects of a lateral semicircular canal (LSCC) fistula, destruction of stapes, localization of cholesteatoma, and air-bone gap (ABG) size on SNHL. The charts of 159 patients who had received surgery for unilateral cholesteatoma were examined retrospectively. In all patients, air conduction and bone conduction (BC) thresholds in both ears were measured at 500, 1000, 2000, and 4000 Hz. Differences in BC thresholds between ears with cholesteatoma and contralateral ears were calculated. Demographics, localization of cholesteatoma, presence of LSCC fistula, condition of stapes, and ABG size on the affected ear were evaluated. There were significantly greater BC thresholds in ears with cholesteatoma than in normal ears for each frequency. Comparing the average BC differences at the different cholesteatoma locations, there were significant differences between the tympanic cavity + all mastoid cell group and attic, attic + antrum, and tympanic cavity + antrum groups. The BC differences at 4000 Hz were significantly high in patients with LSCC fistula. There were no significant relationships between the condition of the stapes and BC differences at any frequencies. There were significant correlations between average ABG and BC threshold differences at all frequencies. A significant relationship was found between cholesteatoma and SNHL. Patients with advanced cholesteatoma had significantly higher levels of SNHL. The BC threshold differences increased with increases in the ABG.

Evaluation of Pediatric Preseptal Cellulitis Cases Diagnosed with Meningitis by Magnetic Resonance Imaging.

Rhinosinusitis is a common infection and may rarely cause severe life-threatening orbital and intracranial complications. In this study, two cases with preseptal cellulitis and meningitis as a complication of rhinosinusitis were presented in the light of the literature. A nine years and two months old girl was admitted with complaints as fever, redness and swelling in the left eye. Physical examination revealed erythema and edema in the left lower and upper eyelids, and the eye movements were painless and normal in all directions. Her systemic examination was normal and there was no sign of meningeal irritation. Magnetic resonance imaging revealed ethmoid, frontal and sphenoid sinusitis and left cerebral hemisphere dural meningeal contrast enhancement. The patient was diagnosed with meningitis after lumbar puncture. After 14 days of appropriate antibiotic treatment, the patient recovered and was discharged. An eight years and five months old boy presented with fever, redness and swelling in the left eye was admitted. There were erythema and edema in the left lower and upper eyelid; the eye movements were painless in all directions and were complete. Systemic examination was normal; there was no sign of meningeal irritation. Pansinusitis and preseptal cellulitis findings were detected on computer tomography. The patient's fever persisted under treatment and erythema and edema of the eye became more evident. Orbital MRI was performed considering the complication and contrast enhancement was observed in the left frontal region. The patient was diagnosed with meningitis after lumbar puncture. After 14 days of appropriate antibiotic treatment, the patient recovered and was discharged. Intracranial complication due to preseptal sinusitis is rare but life-threatening. In these cases, we recommend the use of MRI as the radiological imaging method.

Accessory Nerve Anatomy in Anterior and Posterior Cervical Triangle: A Fresh Cadaveric Study.

OBJECTIVE: To understand the variations and normal course of the accessory nerve (CNXI) to help more accurate and confident neck dissection. METHODS: The course of the CNXI in the neck, its relationship to the surrounding anatomic structures and the factors affecting its course were investigated. RESULTS: A total of 100 neck dissections were performed on 50 fresh cadavers. Eleven division variations were observed at the anterior triangle. The location of CNXI at the posterior border of the sternocleidomastoid muscle (PBSCM) was investigated and the ratio between the distance from the mastoid apex (MAA) to CNXI at the PBSCM and the distance from MAA to the posterior border where the PBSCM is attached to the clavicle increased as height of the subject increased (p<0.05). CONCLUSION: It must be kept in mind that it is better to search for CNXI in taller subjects more inferiorly at the posterior border of the sternocleidomastoid muscle.

Olfactory bulb magnetic resonance imaging in SARS-CoV-2-induced anosmia in pediatric cases.

In this paper, we report three cases of pediatric patients with COVID-19 infection who presented with different symptoms and also anosmia and/or ageusia. The common feature of these 3 patients is that the smell and / or taste disorder developed without nasal symptoms such as nasal congestion, nasal obstruction or rhinorrhea. Although 40% of anosmies contains viral etiologies, COVID- 19 differs from other viral anosmies by the lack of nasal congestion and runny nose. Coronaviruses could invade the brain via the cribriform plate close to the olfactory bulb and the olfactory epithelium. We may expect some structural changes in the olfactory bulb so we evaluated our patient with cranial imaging.

Taste and Smell Impairment in COVID-19: An AAO-HNS Anosmia Reporting Tool-Based Comparative Study.

OBJECTIVE: To identify the taste and smell impairment in coronavirus disease 2019 (COVID-19)-positive subjects and compare the findings with COVID-19-negative subjects using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Anosmia Reporting Tool. SETTING: Tertiary referral center/COVID-19 pandemic hospital. STUDY DESIGN: Comparative study. SUBJECTS AND METHODS: After power analysis, 128 subjects were divided into 2 groups according to real-time polymerase chain reaction (RT-PCR) COVID-19 testing results. Subjects were called via telephone, and the AAO-HNS Anosmia Reporting Tool was used to collect responses. RESULTS: The mean age of the study group was 38.63 ± 10.08 years. At the time of sampling, rhinorrhea was significantly high in the COVID-19-negative group, whereas those complaints described as "other" were significantly high in the COVID-19-positive group. There was a significant difference in the smell/taste impairment rates of the groups (n = 46% [71.9%] for the COVID-19-positive group vs n = 17 [26.6%] for the COVID-19-negative group, P = .001). For subjects with a smell impairment, anosmia rates did not differ between the groups. The rates of hyposmia and parosmia were significantly high in the COVID-19-positive group. For the subjects with taste impairment, ageusia rates did not differ between groups. The rate of hypogeusia and dysgeusia was significantly high in the COVID-19-positive group. Logistic regression analysis indicates that smell/taste impairment in COVID-19-positive subjects increases the odds ratio by 6.956 (95% CI, 3.16-15.29) times. CONCLUSION: COVID-19-positive subjects are strongly associated with smell/taste impairment.

Taste and Smell Impairment in SARS-CoV-2 Recovers Early and Spontaneously: Experimental Data Strongly Linked to Clinical Data.

A growing body of literature indicates that smell and taste impairment has frequently occurred during the Severe Acute Respiratory Syndrome (SARS)-like Coronavirus (SARS-CoV-2) outbreak. Experimental studies have mostly found that non-neural-type cells are responsible for SARS-CoV-2-related taste and smell impairment. If this is the case, smell/taste impairment needs to recover early. Literature data from clinical studies indicated a strong correlation between experimental and clinical findings. This article presents clinical studies related to SARS-CoV-2-induced smell/taste impairment that reported recovery rates. Experimental researchers may use these data to observe the dynamics of smell impairment and implement these findings in their research (e.g., correct timing of sampling) to perform further studies.

The Ignored Parameter in the Diagnosis of Obstructive Sleep Apnea Syndrome: The Oxygen Desaturation Index.

OBJECTIVE: The apnea-hypopnea index (AHI) does not provide information about the apnea depth and length. We aimed to evaluate the correlation of the oxygen desaturation index (ODI) with AHI and the subjective symptoms because it is known that hypoxia plays an important role in morbidity and complications of obstructive sleep apnea syndrome (OSAS). METHODS: We reviewed the data of patients who applied to our clinic between 2010 and 2014 and underwent polysomnography (PSG) with a diagnosis of suspected sleep apnea. The demographic and anthropometric data of the patients were recorded. Epworth sleepiness scale (ESS) and values of AHI and ODI were analyzed in PSG. RESULTS: A total of 321 patients were divided into four groups, according to AHI as follows: 82 (25.5%) common snoring, 77 (24%) mild obstructive sleep apnea (OSA), 71 (22.1%) moderate OSA, and 91 (28.3%) severe OSA. A strong correlation was detected between AHI and ODI (p<0.005 and r=0.904) in all patient groups. There was a positive correlation between AHI and ESS (p<0.05 and r=0.435), but the correlation of ESS with ODI was stronger than that with AHI (p<0.05 and r=0.504). CONCLUSION: The subjective symptoms of sleep apnea syndrome seem to be closely related to oxygen desaturations. Hypoxia during apnea periods of OSA is important; therefore, we suggest that ODI is as valuable as AHI in diagnosing and grading the OSAS.

PlasmaBlade vs. cold dissection tonsillectomy: A prospective, randomized, double-blind, controlled study in adults.

We conducted a prospective, randomized, double-blind, controlled clinical study to compare the efficacy and safety of the PlasmaBlade device and cold dissection for adult tonsillectomy. Our study group was made up of 20 patients-12 men and 8 women, aged 18 to 50 years (mean: 27.1)-who were undergoing a bilateral tonsillectomy. Each patient had one randomly chosen tonsil removed by the PlasmaBlade and the other by cold instrumentation. We compared the duration of surgery, the amount of intraoperative blood loss, the number of sutures required, the status of tonsillar fossa wound healing at 7 and 14 days postoperatively, the amount of postoperative pain, and postoperative complications. We found statistically significant differences in the amount of blood loss and the number of sutures in favor of the PlasmaBlade technique. No significant differences were observed in any of the other outcomes.