Objective and subjective cognitive status after intensive care unit treatment for COVID-19.

Purpose: Intensive care unit (ICU) survivors can experience wide-ranging and long-lasting symptoms after hospital discharge. Cognitive impairment has received increased attention in relation to the COVID-19 pandemic and can affect patients' long-term quality of life. This study aimed to investigate the prevalence of cognitive impairment using an objective neurocognitive test 6 and 12 months following ICU admission and possible predictive factors for scoring below the defined cut-off. We also explored the prevalence of subjective cognitive complaints at 12 months, including the associated factors. Methods: This was a prospective observational study of a national cohort of COVID-19 ICU survivors during the three first pandemic waves in Norway. Data was collected by the Norwegian Intensive Care and Pandemic Registry and the study group. Results: At the six-month follow-up, 23.1% (95% CI [18.2─28.5]) of the 273 respondents scored below the cut-off on the Mini-MoCA, indicating mild cognitive impairment. At the 12-month follow-up, the prevalence declined to 11.1% (95% CI [7.5─15.6]) in 253 respondents. Older age (OR 1.06, 95% CI [1.02─1.12]) and depression (OR 1.25, 95% CI [1.07─1.55]) were associated with cognitive impairment at six months. At 12 months, almost half of the patients reported subjective cognitive complaints. Symptoms of mental health problems and fatigue were associated with subjective cognitive complaints in our exploratory analyses. Conclusion: Cognitive impairment declined significantly from 6 to 12 months in this cohort of COVID-19 ICU patients, while subjective cognitive complaints remained high at 12 months, perhaps attributed to a high total symptom burden.

The relationship between gender, psychosocial factors, pain, health literacy and health-related quality of life in parents of Norwegian adolescents one year into the COVID-19 pandemic.

BACKGROUND: Stress impacts healthy behaviours and may influence life and health-related quality of life (HRQOL). A stressful event occurred when the COVID-19 pandemic hit in March 2020. The present study aims to explore possible gender differences in stress, psychosocial factors (self-efficacy, self-esteem, loneliness), pain, HL, and HRQOL in parents of adolescents one year into the COVID-19 pandemic, and to explore possible associations between gender, demographic and psychosocial factors, pain, HL, and HRQOL. METHODS: Parents of adolescents aged 16-17 took part in the study from January to February 2021, when the COVID-19 pandemic was ongoing. Data on socio-demographics, stress, self-efficacy, self-esteem, pain, HL, loneliness, and HRQOL were collected. HRQOL was assessed using RAND-36. RESULTS: Among the 320 parents from the general population, the mean age was 47.6 (standard deviation (SD) = 4.6) years, 81% were mothers, 79% were married or cohabiting, 81% had a university degree, and the majority worked full time (78%) or part time (13%). The average pain score was low, 0.48 (95% CI [0.43-0.54]). However, 50% of the parents reported persistent pain and more mothers reported persistent pain compared to fathers (53% vs. 37%). The parents' mean (SD) score for RAND-36 was 52.1 (95% CI [51.2-53.0]) for the physical component summary (PCS) score and 51.0 (95% CI [50.0-52.1]) for the mental component summary (MCS) score. Mothers reported significantly lower scores for all the eight RAND-36 domains and the PCS and MCS scores. Adjusting for gender, age, living condition, education, pain, HL, self-efficacy and loneliness, we revealed no associations between stress and RAND-36-PCS. University education of four years or more was positively associated (B = 3.29, 95% CI: [0.78-5.80]) with RAND-36-PCS, while persistent pain was negatively associated (B = -7.13, CI: [-9.20- -5.06]). We identified a strong negative association between RAND-36-MCS and stress (B = -43.11, CI: [-48.83- -37.38]) and a positive association with older age (B = 0.21, CI: [ 0.04, 0.39)]. CONCLUSION: One year into the COVID-19 pandemic, we identified a strong negative association between stress and mental HRQOL, while pain was strongly negatively associated with physical HRQOL.

Inter-rater agreement between patient- and proxy-reported cognitive functioning in intensive care unit patients: A cohort study.

BACKGROUND: Health status, including cognitive functioning before critical illness, is associated with long-term outcomes in intensive care unit survivors. Premorbid data are therefore of importance in longitudinal studies. Few patients can self-report at intensive care admission. Consequently, proxy assessments of patients' health status are used. However, it remains unclear how accurately proxies can report on an intensive care patient's cognitive status. OBJECTIVES: The aim of this study was to examine the agreement between patient- and proxy-reporting of the Cognitive Failures Questionnaire and to compare the agreement between proxy reports using the latter questionnaire and the Informant Questionnaire of Cognitive Decline in the Elderly as a reference. METHODS: The present cohort study is part of a longitudinal multicentre study collecting both patient and proxy data using questionnaires and clinical data from medical records during intensive care unit stays. Agreement on patient and proxy pairs was examined using intraclass correlation coefficient (ICC), Spearman's correlation, percentage agreement, and Gwet's AC1 statistics. Agreement between the proxy-reported questionnaires was examined using percentage agreement and Gwet's AC1 statistics. RESULTS: In total, we collected 99 pairs of patient-proxy assessments and 158 proxy-proxy assessments. The ICC for the sum scores revealed moderate agreement (n = 99; ICC = 0.59; 99% confidence interval [CI]: [0.30-0.76]) between patient and proxy. Agreement on items was poor (AC1 = 0.13; 99% CI: [0.01-0.24]) to moderate (AC1 = 0.55; 99% CI: [0.43-0.68]). Agreement using cut-off scores (>43) to indicate cognitive impairment was very good (89.9%, AC1 = 0.87; 99% CI: [0.79-0.95]). Agreement between the proxy-reported Cognitive Failures Questionnaire (>43) and the reference questionnaire (≥3.5) was also very good (n = 158; 85%, AC1 = 0.82; 99% CI: [0.74-0.90]). CONCLUSIONS: Proxy assessments of the Cognitive Failures Questionnaire (>43) may be used to indicate cognitive impairment if patients are unable to self-report. Agreement was high between the two questionnaires determined by proxies, showing that these can be used interchangeably to assess cognitive functioning if proxy reporting is needed.

Patient characteristics associated with posttraumatic stress symptoms in intensive care unit survivors during a one-year follow-up: A multicenter study.

BACKGROUND: Intensive care unit (ICU) patients are at risk of suffering from posttraumatic stress symptoms (PTSS) after ICU survival. OBJECTIVES: To describe the prevalence of high levels of PTSS the first year after ICU admission. Further, to identify specific combinations of patient characteristics (latent classes based on pre-ICU data, demographics, and clinical characteristics), and to investigate possible associations among these classes and PTSS at 3, 6, and 12 months after ICU admission. METHODS: Self-reported PTSS were measured with Impact of Event Scale-Revised (IES-R). PTSS and possible predictive factors (pre-ICU data, demographics, and clinical characteristics) were analyzed using descriptive statistics, latent class analysis, and linear mixed model for repeated measures. RESULTS: High PTSS levels (IES-R ≥ 33) were reported by 14.9 % (95 % confidence interval [CI] [10.0; 21.1]), 16.7 % (95 % CI [11.5; 23.1]), and 18.4 % (95 % CI [12.9; 25.0]) of patients (sample 1, n = 174) at 3, 6, and 12 months, respectively. Three latent classes were identified (sample 2, n = 417). PTSS were significantly associated with class 2 (male with longer hospital stay) at 6 months and class 3 (age≥70, lower level of education, higher Simplified Acute Physiology Score, being mechanically ventilated) at all three measurement times. CONCLUSIONS: The prevalence of high levels of PTSS is the greatest 12 months after ICU admission. Health professionals can use this information to be aware of specific groups of ICU patients reporting PTSS during the first year and follow up on these.

Subcutaneous Vedolizumab Treatment in a Real-World Inflammatory Bowel Disease Cohort Switched From Intravenous Vedolizumab: Eighteen-Month Prospective Follow-up Study.

Background: Vedolizumab has since 2021 been available as a subcutaneous formulation. We aimed to assess 18-month drug persistence and possible predictive factors associated with discontinuation, safety, serum drug profile, drug dosing, and disease activity in a real-world cohort of patients with inflammatory bowel disease switched from intravenous to subcutaneous vedolizumab maintenance treatment. Methods: Eligible patients were switched to subcutaneous vedolizumab and followed for 18 months or until discontinuation of subcutaneous treatment. Data on preferred route of administration, adverse events, drug dosing, serum-vedolizumab, disease activity, fecal calprotectin, and C-reactive protein were collected. Persistence was described using Kaplan-Meier analysis. The impact of clinical and biochemical variables on persistence was analyzed with Cox proportional hazard models. Results: We included 108 patients, and the estimated 18-month drug persistence was 73.6% (95% CI [64.2-80.1]). Patients in clinical remission at switch were less likely to discontinue SC treatment (HR = 0.34, 95% CI [0.16-0.73], P = .006), and patients favoring intravenous treatment at switch were almost 3 times more likely to discontinue (HR = 2.78, 95% CI [1.31-5.90], P = .008). Four patients discontinued subcutaneous vedolizumab due to injection site reactions. At 18 months, 88% of patients administered subcutaneous vedolizumab with an interval of ≥ 14 days, and serum-vedolizumab was 39.1 mg/L. Disease activity was stable during follow-up. Conclusions: Three of the four patients remained on subcutaneous vedolizumab after 18 months, a large proportion received treatment at standard dosing intervals, and disease activity remained stable. This indicates that switching from intravenous to subcutaneous vedolizumab treatment is convenient and safe.

Open-door policy versus treatment-as-usual in urban psychiatric inpatient wards: a pragmatic, randomised controlled, non-inferiority trial in Norway.

BACKGROUND: Open-door policy is a recommended framework to reduce coercion in psychiatric wards. However, existing observational data might not fully capture potential increases in harm and use of coercion associated with open-door policies. In this first randomised controlled trial, we compared coercive practices in open-door policy and treatment-as-usual wards in an urban hospital setting. We hypothesised that the open-door policy would be non-inferior to treatment-as-usual on the proportion of patients exposed to coercive measures. METHODS: We conducted a pragmatic, randomised controlled, non-inferiority trial comparing two open-door policy wards and three treatment-as-usual acute psychiatric wards at Lovisenberg Diaconal Hospital in Oslo, Norway. An exemption from the consent requirements enabled inclusion and random allocation of all patients admitted to these wards using an open list (2:3 ratio) administrated by a team of ward nurses. The primary outcome was the proportion of patient stays with one or more coercive measures, including involuntary medication, isolation or seclusion, and physical and mechanical restraints. The non-inferiority margin was set to 15%. Primary and safety analyses were assessed using the intention-to-treat population. The trial is registered with ISRCTN registry and is complete, ISRCTN16876467. FINDINGS: Between Feb 10, 2021, and Feb 1, 2022, we randomly assigned 556 patients to either open-door policy wards (n=245; mean age 41·6 [SD 14·5] years; 119 [49%] male; 126 [51%] female; and 180 [73%] admitted to the ward involuntarily) or treatment-as-usual wards (n=311; mean age 41·6 [4·3] years; 172 [55%] male and 138 [45%] female; 233 [75%] admitted involuntarily). Data on race and ethnicity were not collected. The open-door policy was non-inferior to treatment-as-usual on all outcomes: the proportion of patient stays with exposure to coercion was 65 (26·5%) in open-door policy wards and 104 (33·4%) in treatment-as-usual wards (risk difference 6·9%; 95% CI -0·7 to 14·5), with a similar trend for specific measures of coercion. Reported incidents of violence against staff were 0·15 per patient stay in open-door policy wards and 0·18 in treatment-as-usual wards. There were no suicides during the randomised controlled trial period. INTERPRETATION: The open-door policy could be safely implemented without increased use of coercive measures. Our findings underscore the need for more reliable and relevant randomised trials to investigate how a complex intervention, such as open-door policy, can be efficiently implemented across health-care systems and contexts. FUNDING: South-Eastern Norway Regional Health Authority and The Research Council of Norway.

The effect of the association between food budget and food quality on adherence to national guidelines in kindergartens, and the impact of budget limit on the food quality.

Background: In Norway, almost 97% of children attend kindergartens. Most of the daily food intake happens during the day in kindergartens, and the quality of food and meals being served is essential to promote healthy food habits. There is variation in the food that kindergartens provide, and kindergartens can ask for additional payment from parents to cover the food. There are no rules neither across kindergartens for the food offering nor how much additional payment kindergarten can request. Objective: Our main objective is to investigate possible associations between the food budget and the quality of food offered in kindergartens. We specifically aimed to identify budget levels that were associated with better adherence to national guidelines, thereby the quality of the food provided, as recommended by the Norwegian Directorate of Health. Design: A cross-sectional study design, based on kindergarten pedagogical leaders' answers to a web-based questionnaire. Settings: Private and public kindergartens across Norway are included in this present study. Participants: A total of 324 kindergarten staff attending on behalf of kindergartens participated. Results: The food budget thresholds over NOK 199 are associated with higher quality of served food, in adherence to national guidelines of food and meals (odds ratio 5.2, CI = [1.5, 16.5]), compared to thresholds under 199 NOK. However, increasing the monthly food budget per child to low (200-299 NOK), medium (300-399 NOK), high (400-499 NOK), or very high (>500 NOK) levels did not lead to an improvement in food quality. Conclusion: The main results reveal that budget plays a limited role in the quality of food and meals served as long as it is above 'very low' (199 NOK) food budget threshold. We assume that other contextual factors can influence the quality of food and meals in a more prominent role.

Long-term functional disabilities in intensive care unit survivors: A prospective cohort study.

BACKGROUND: Functional disabilities are common in intensive care unit (ICU) survivors and may affect their ability to live independently. Few previous studies have investigated long-term functional outcomes with health status before ICU admission (pre-ICU health), and they are limited to specific patient groups. OBJECTIVES: The objective of this study was to investigate the prevalence of functional disabilities and examine pre-ICU health variables as possible predictive factors of functional disabilities 12 months after ICU admission in a mixed population of ICU survivors. METHODS: This prospective cohort study was conducted in six ICUs in Norway. Data on pre-ICU health were collected as soon as possible after ICU admission using patients, proxies, and patient electronic health records and at 12 months after ICU admission. Self-reported functional status was assessed using the Katz Index of independence in personal activities of daily living (P-ADL) and the Lawton instrumental activities of daily living scale (I-ADL). RESULTS: A total of 220 of 343 (64%) ICU survivors with data on pre-ICU health completed the questionnaires at 12 months and reported the following functional disabilities at 12 months: 31 patients (14.4%) reported P-ADL dependencies (new in 16 and persisting in 15), and 80 patients (36.4%) reported I-ADL dependencies (new in 41 and persisting in 39). In a multivariate analysis, worse baseline P-ADL and I-ADL scores were associated with dependencies in P-ADLs (odds ratio [OR]: 1.87; 95% confidence interval [CI]: 1.14-3.06) and I-ADLs (OR: 1.52; 95% CI: 1.03-2.23), respectively, at 12 months. Patients who were employed were less likely to report I-ADL dependencies at 12 months (OR: 0.34; 95% CI: 0.12-0.95). CONCLUSION: In a subsample of ICU survivors, patients reported functional disabilities 12 months after ICU admission, which was significantly associated with their pre-ICU functional status. Early screening of pre-ICU functional status may help identify patients at risk of long-term functional disabilities. ICU survivors with pre-ICU functional disabilities may find it difficult to improve their functional status.

Factors associated with pain and functional impairment five years after total knee arthroplasty: a prospective observational study.

BACKGROUND: Few studies have evaluated the associations between preoperative factors and pain and physical function outcomes after total knee arthroplasty (TKA) from a mid-term perspective. Identification of such factors is important for optimizing outcomes following surgery. Thus, we examined the associations between selected preoperative factors and moderate to severe pain and pain-related functional impairment as measured using the Brief Pain Inventory (BPI), five years after TKA in patients with knee osteoarthritis. METHODS: In this prospective observational study, all patients scheduled for primary unilateral TKA for osteoarthritis were consecutively recruited. Preoperative factors identified from previous meta-analyses were included to assess their associations with pain severity and pain-related functional impairment five years after TKA. Pain severity was the primary outcome, while pain-related functional impairment was the secondary outcome. The BPI was used to evaluate outcomes five years post-TKA. Statistically significant factors from univariate regressions were entered into a multiple logistic regression model to identify those with the strongest associations with pain severity or pain-related functional impairment five years after TKA. RESULTS: A total of 136 patients were included, with a mean age of 67.7 years (SD 9.2) and a majority being female (68%). More severe preoperative pain (OR = 1.34, 95% CI [1.03 to 1.74]), more painful sites (OR = 1.28., 95% CI [1.01 to 1.63]), and more severe anxiety symptoms (OR = 1.14., 95% CI [1.01 to 1.28]) were associated with increased likelihood of moderate to severe pain five years after TKA surgery, while more severe osteoarthritis (OR = 0.13, 95% CI [0.03 to 0.61]) was associated with reduced likelihood of moderate to severe pain five years after TKA. More severe anxiety symptoms (OR = 1.25, 95% CI [1.08 to 1.46]) were also associated with increased likelihood of moderate to severe pain-related functional impairment five years after surgery, while male sex (OR = 0.23, 95% CI [0.05 to 0.98]) was associated with reduced likelihood of pain-related functional impairment five years after surgery. CONCLUSION: The identified preoperative factors should be included in larger prognostic studies evaluating the associations between preoperative factors and mid-term pain severity and physical function outcomes after TKA surgery.

The use of youth healthcare services and its association with health-related quality of life, physical and mental health and over-the-counter analgesics use in 13-19-year-old adolescents: a cross-sectional study.

BACKGROUND: Youth healthcare services in Norway include a public health nurse (PHN) at school and local youth health centres (YHCs). They provide health services for all adolescents free of charge, focusing on health promotion and disease prevention. The present study aimed to assess possible associations between health-related quality of life (HRQoL), physical and mental health, over-the-counter analgesics (OTCA) use and use of youth healthcare services among 13-19-year-old adolescents. METHODS: This study was based on national, cross-sectional data from the Ungdata Survey conducted in 2022. The sample was comprised of 16 482 adolescents. Multiple logistic regression was used to analyse the associations between HRQoL, headaches, selected physical symptoms, psychological distress, use of OTCA, PHN availability, sociodemographic variables, and use of the PHN at school or at a YHC. The KIDSCREEN-10 was used to measure HRQoL, and the Hopkins Symptoms Checklist 10 was used to measure symptoms of psychological distress. RESULTS: Girls used the youth healthcare services more frequently than boys. Better HRQoL was significantly associated with fewer visits to the PHN at school. Girls reported lower HRQoL and mental health, and more pain and frequent OTCA use than boys. When having symptoms of psychological distress, boys had greater odds of visiting the PHN at school than girls. For girls in senior high school, headaches and OTCA use were strongly associated with visiting the PHN at school and the YHC. In senior high school, boys with an immigration background had greater odds of visiting the YHC than native Norwegian boys, while girls with an immigration background were less likely to visit the YHC than native Norwegian girls. CONCLUSIONS: Our results show that more girls than boys use youth healthcare services. When adolescents experience pain, have mental problems, use OTCA, or report low levels of HRQoL, they have greater odds of using youth healthcare services. Youth healthcare services offer excellent opportunities to support and follow up with adolescents. The findings provide important insights into youth healthcare services used by adolescents for various stakeholders, including PHNs and policy makers, with potential implications for future public health efforts.

Associations between modifiable lifestyle factors and health-related quality of life among endometrial carcinoma survivors - A cross-sectional study.

OBJECTIVE: To explore possible associations between modifiable lifestyle factors and health-related quality of life (HRQoL) in endometrial carcinoma survivors by assessing differences in HRQoL between survivors meeting and not meeting the World Health Organization's (WHO) recommendations regarding physical activity, BMI, and smoking. METHODS: This was a cross-sectional population-based study in women having undergone surgery for assumed early-stage endometrial carcinoma. Thresholds for clinical importance based on the EORTC QoL working group were used to interpret scores. Effect size (ES) was interpreted as small (d = 0.2-0.49), medium (d = 0.5-0.8), and large (d > 0.8). RESULTS: In total, 1200 evaluable women were included. Meeting physical activity recommendations and BMI <25 kg/m2 was associated with significantly better global health status, (ES) = 0.18 and ES = -0.11, respectively. On multivariate analysis, women meeting physical activity recommendations had significantly higher scores on physical- (ES = 0.31), role- (ES = 0.15), and social functioning (ES = 0.15), and lower levels of fatigue (ES = -0.16), pain (ES = -0.10), and appetite loss (ES = -0.15) (all p < 0.05) compared to non-meeting survivors. Participants with BMI ≥25 kg/m2 had lower scores for social functioning (ES = -0.10), and higher levels of pain (ES = 0.13) and dyspnea (ES = 0.12) (all p < 0.05) compared to those with BMI <25 kg/m2. Smokers had lower scores for emotional functioning (ES = -0.09) and higher levels of diarrhea (ES = 0.10) (all p < 0.05) compared to non-smokers. CONCLUSION: Meeting WHO recommendations for modifiable life-style factors is associated with better HRQoL among endometrial carcinoma survivors: Being sufficiently physical active and having a BMI <25 kg/m2 are significantly associated with better self-reported global health status. All modifiable factors are associated with better functioning, and reduced symptom-burden.

Self-reported symptoms experienced by intensive care unit patients: a prospective observational multicenter study.

PURPOSE: The purpose of this study is to describe the prevalence, intensity and distress of five symptoms in intensive care unit (ICU) patients and to investigate possible predictive factors associated with symptom intensity. METHODS: This is a prospective cohort study of ICU patients. A symptom questionnaire (i.e., Patient Symptom Survey) was used to describe the prevalence, intensity and distress of pain, thirst, anxiousness, tiredness, and shortness of breath over seven ICU days. Associations between symptom intensity and possible predictive factors were assessed using the general estimating equation (GEE) model. RESULTS: Out of 603 eligible patients, 353 (Sample 2) were included in the present study. On the first ICU day, 195 patients (Sample 1) reported thirst as the most prevalent symptom (66%), with the highest mean intensity score (6.13, 95% confidence interval (CI) [5.7-6.56]). Thirst was the most prevalent (64%) and most intense (mean score 6.05, 95%CI [5.81-6.3]) symptom during seven days in the ICU. Anxiousness was the most distressful (mean score 5.24, 95%CI [4.32-6.15]) symptom on the first day and during seven days (mean score 5.46, 95%CI [4.95-5.98]). During seven days, analgesic administration and sepsis diagnosis were associated with increased thirst intensity. Older age and being mechanically ventilated were associated with decreased pain intensity, and analgesic administration was associated with increased pain intensity. Family visits and female gender were associated with increased intensity of anxiousness and shortness of breath, respectively. CONCLUSIONS: Self-reporting ICU patients experienced a high and consistent symptom burden across seven days. Certain variables were associated with the degree of symptom intensity, but further research is required to better understand these associations.

Intraoperative distensibility measurement in POEM for achalasia: impact on patient outcome and associations with other outcome variables at 1-year follow-up.

BACKGROUND AND AIMS: The functional luminal imaging probe (FLIP) can provide measurements of lower esophageal sphincter (LES) distensibility. Studies report that use of intraoperative FLIP examination during peroral endoscopic myotomy (POEM) for achalasia is associated with treatment success, but evidence is limited and inconsistent. The main aim of the present study was to assess associations between intraoperative FLIP values and 1-year outcomes. Additionally, associations between 1-year FLIP measurements and other 1-year outcome variables were studied. METHODS: We performed a single-center prospective study of consecutive achalasia patients treated with POEM with a standardized 1-year follow-up. The inclusion period was from June 2017 to January 2020. We compared 1-year outcomes (FLIP measurement values, Eckardt score (ES), reflux esophagitis, timed barium esophagogram (TBE), and lower esophageal sphincter resting pressure (LES-rp)) in patients with and without intraoperative FLIP examination. We also assessed associations between intraoperative FLIP values, 1-year FLIP values, and other 1-year outcomes. Results are given as median (IQR), and non-parametrical statistical analyses were applied. RESULTS: Sixty-two patients (27 females) with median age 45 years (35-54) were included. Baseline characteristics were similar in patients with (n = 32) and without (n = 30) intraoperative FLIP examination. In patients with intraoperative FLIP, ES was 2 (1-3) and LES distensibility index (DI) 3.7 (2.6-5.4) after 1 year, compared with ES 2 (1-3) and DI 4.0 (3.1-6.8)) in patients without intraoperative FLIP (ns). Intraoperative DI was not correlated with 1-year ES or DI. One-year DI correlated significantly with 1-year ES (rs - 0.42), TBE (rs - 0.34), and LES-rp (rs - 0.29). CONCLUSIONS: Use of intraoperative FLIP measurements in POEM for achalasia is not associated with improved 1-year outcome, and the clinical value of intraoperative FLIP in POEM for achalasia is questioned. Follow-up FLIP measurements are moderately associated with symptomatic outcome, and may serve as an additional diagnostic modality in post-treatment evaluation.