Voice-Related Quality of Life in Patients with Chronic Rhinosinusitis.

OBJECTIVE: Chronic rhinosinusitis (CRS) has long been associated with vocal dysfunction. However, studies quantifying the presence of voice dysfunction in CRS patients or the effects of functional endoscopic sinus surgery (FESS) are sparse. The goal of this study was to determine the voice-related quality of life in patients undergoing FESS for CRS using the validated Voice Related Quality of Life Survey (VRQL). We correlated the preoperative VRQL scores to the Sino-Nasal Outcome Test (SNOT-22) scores, and we determined the effect of FESS on postoperative VRQL scores. METHODS: Consecutive patients undergoing FESS were preoperatively administered both the VRQL and the SNOT-22 surveys. Spearman (ρ) and Pearson (r) correlation coefficients were calculated. The VRQL was mailed to patients postoperatively between 3 and 6 months. The paired t-test was used to compare pre- and post-FESS scores. RESULTS: A total of 102 patients were enrolled, and 81 patients completed the two surveys. A total of 51 (62.9%) patients had raw VRQL score ≥ 10, signifying presence of significant vocal symptoms. The mean ± standard deviation (SD) raw VRQL score of the entire study population was 12.4 ± 4.6, and the mean SNOT-22 score was 37.8 ± 19.2. The Spearman correlation coefficient between VRQL and the total SNOT-22 score was 0.34 (P =.002), and the Pearson correlation coefficient was 0.36 (P = .001). Both correlations were similar, demonstrating that increasing severity of CRS symptoms correlates with decreasing voice-related quality of life (QOL). Seventy patients completed the postoperative survey for an 86% retention rate. Thirty-six of these patients had abnormal preoperative VRQL scores, and these patients improved significantly after FESS. The mean preoperative versus postoperative raw scores were 15.2 ± 5.6 versus 12.5 ± 4.1, respectively (P = .003). CONCLUSION: This study demonstrates the increasing presence of vocal complaints with increasing severity of CRS. It also demonstrates that VRQL scores improve after FESS in those patients with preoperative vocal complaints. LEVEL OF EVIDENCE: IV.

The Effect of the Speech Task Characteristics on Perceptual Judgment of Mild to Moderate Dysphonia: A Methodological Study.

OBJECTIVE: To study the differences in perceptual ratings of mild and moderate dysphonia related to the speech task, and their impact on intrarater and interrater reliabilities. PATIENTS AND METHODS: Voice recordings of 15 outpatients with mild or moderate dysphonia related to laryngopharyngeal reflux were presented to 6 female experienced judges blinded to the clinical state of the patients. From these, the GRBASI (Grade, Roughness, Breathiness, Asthenia, Strain, and Instability) evaluations were performed on connected speech and sustained vowel of the pretreatment voice recordings and absolute agreement, and both intrarater and interrater reliabilities were assessed. RESULTS: The average GRBASI scores were significantly worse when performed on sustained vowel. Intrarater reliability substantially varied according to the judge and the task. Good interrater reliability was broadly found for the evaluations of all GRBASI components irrespective of the speech task. Concerning agreement, we only found absolute agreement between judges for G and R items assessed on text. CONCLUSION: Average grade of perceptual voice impairment, intrarater reliability, and agreement vary according to the speech task.

Association between late effects assessed by physicians and quality of life reported by head-and-neck cancer survivors.

BACKGROUND: Many survivors of head-and-neck cancer (HNC) suffer from late effects. Their overall quality of life deteriorates during treatment, followed by a slow recovery up to five years after treatment. We examined the association between the severity of physician-assessed late effects and the health-related quality of life (HRQoL) reported by survivors of HNC. MATERIAL AND METHODS: The analysis was based on data collected during follow-up for 136 survivors of cancer in the oral cavity, pharynx, larynx, or salivary glands. Physicians' assessments of dysphagia, xerostomia, fibrosis, and hoarseness, derived from reports to of the Danish Head and Neck Cancer Group database and patient-reported overall quality of life and social, role, emotional, cognitive, and physical functioning reported on the European Organization for Research and Treatment of Cancer questionnaire. Linear regression models were used to examine the association between the severity of each late effect and HRQoL. RESULTS: Quality of life was decreased among patients with moderate to severe dysphagia compared to patients without dysphagia (-16 points; 95% CI -21;-3). Also role functioning (-20 points; 95% CI -38;-2), emotional functioning (-19 points; 95% CI -34;-4) and social functioning (-27 points; 95% CI -41;-13) decreased compared with patients without dysphagia. Mild dysphagia was also associated with decreased overall quality of life (-12 points; 95% CI -21;-3). Moderate to severe hoarseness was significantly associated with poorer social functioning (-25 points; 95% CI -41;-10). There was no association between fibrosis or xerostomia and HRQoL. CONCLUSION: Physician-assessed moderate to severe hoarseness and mild, moderate, or severe dysphagia are associated with clinically relevant decreases in patient-reported quality of life and functioning. Fibrosis and xerostomia of any severity were not associated with changes in any scale of functioning in this study population.

Phonatory symptoms and impact on quality of life in female patients with goiter.

Our objective is to report on the prevalence of phonatory symptoms and impact on quality of life in a group of female patients with goiter who had not been selected for surgery or who had not presented to the emergency room with respiratory distress. A total of 40 patients with goiter and 14 controls were enrolled in this study. Demographic data included age, sex, laryngopharyngeal reflux disease, allergy, smoking, duration of disease, presence or absence of compressive symptoms, presence or absence of thyroid gland nodules, vascular status, presence or absence of calcifications, and thyroid-stimulating hormone levels. Phonatory symptoms included hoarseness, vocal fatigue, vocal straining, lump sensation, and aphonia. The Voice Handicap Index 10 was used to assess the impact of phonatory symptoms on quality of life. The most common phonatory symptom in the patients with goiter was vocal fatigue followed by lump sensation. The only phonatory symptom that was significantly more present in patients with goiter was vocal straining. As for the impact of phonatory symptoms on quality of life, 15.8% of goiter patients had a Voice Handicap Index score >7 compared with 7.7% of controls. Phonatory symptoms are common in patients with goiter, with vocal straining occurring significantly more frequently than in controls. In 1 of 6 patients, the presence of phonatory symptoms had an impact on quality of life.

Factors Associated With Patient-perceived Hoarseness in Spasmodic Dysphonia Patients.

OBJECTIVES/HYPOTHESIS: The American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines on Hoarseness distinguishes between hoarseness, which is a symptom perceived by the patient, and dysphonia, which is a diagnosis made by the clinician. Our objective was to determine factors that are associated with patient-perceived hoarseness in spasmodic dysphonia (SD) patients. STUDY DESIGN: Retrospective study. METHODS: Adductor SD patients who presented for botulinum toxin injections from September 2011 to June 2012 were recruited. The main outcome variable, Voice Handicap Index-10 (VHI-10), was used to quantify patient-perceived hoarseness. Clinical data, Hospital Anxiety and Depression Scale (HADS), and VHI-10 were collected. Clinician-perceived dysphonia was measured by a speech-language pathologist with Consensus Auditory Perceptual Evaluation of Voice (CAPE-V). Statistical analysis included univariate analyses and multiple linear regression. RESULTS: One hundred thirty-nine SD patients had VHI-10 score of 26.0 ± 7.2 (mean ± standard deviation), disease duration of 10.5 + 7.0 years, CAPE-V overall score of 43.2 ± 21.8, HADS anxiety score of 6.7 ± 3.8, and HADS depression score of 3.6 ± 2.8. In univariate analyses, there were positive correlations (P < 0.05) between VHI-10 and female gender, CAPE-V overall, older age, HADS anxiety, and depression. There was no correlation with professional voice use and disease duration. In multiple linear regression (R2 = 0.178, P < 0.001), age, HADS anxiety, female gender, and CAPE-V were significant. CONCLUSIONS: Older age, higher anxiety levels, female gender, and clinician-perceived dysphonia are associated with higher levels of patient-perceived hoarseness in SD patients. Hoarseness is a very personal symptom. Multiple factors determine its self-perception.

Subjective voice quality, communicative ability and swallowing after definitive radio(chemo)therapy, laryngectomy plus radio(chemo)therapy, or organ conservation surgery plus radio(chemo)therapy for laryngeal and hypopharyngeal cancer.

This retrospective analysis focusses on the impact of therapy on perceived long-term post-cancer treatment function. A validated questionnaire including items and components for the assessment of communicative ability, quality of voice and swallowing was sent to 129 patients. All patients were treated between 1998 and 2007. A total of 76 patients (58.9%) with carcinoma of the larynx or hypopharynx replied to the questionnaire. Data was evaluated retrospectively. Therapy delivered was definitive radio(chemo)therapy (defchRT/RT) (21/76, 28%), laryngectomy + radio(chemo)therapy (LE + chRT/RT) (28/76, 37%), or larynx conservation surgery + radio(chemo)therapy (LCS + chRT/RT) (27/76, 36%). Radiotherapy was administered using 2D- or 3D-conformal planning. The most common concomitant chemotherapy delivered was cisplatin + 5FU. For statistical analyses of the components, averages were calculated and tested using the Kruskal-Wallis test and the U-test of Mann and Whitney. Differences were assessed by the Monte Carlo method or Fisher's exact test. The single item rates were compared with Fisher's exact test. Mean follow-up was 56.7 months (range, 8-130 months). After defchRT/RT, patients trended towards more substantial-strong hoarseness compared with LCS + chRT/RT (P = 0.2). After LE, patients were dissatisfied with their artificial larynx/electrolarynx and the tone of their voice (P = 0.3, P = 0.07) and communicative ability (P = 0.005, P = 0.008) compared with those treated with defchRT/RT and LCS + chRT/RT, respectively. Dysphagia and additional percutaneous endoscopic gastrostomy (PEG) feeding were more frequent after defchRT/RT in comparison with the other two groups (P < 0.05). Voice quality and communicative ability were slightly worse after defchRT/RT and LE + chRT/RT, but satisfying with all treatment modalities. Further development of the therapy approach is necessary to reduce long-term side effects, with measures of post-treatment function as important endpoints.

Language-independent automatic evaluation of intelligibility of chronically hoarse persons.

OBJECTIVE: Automatic intelligibility assessment using automatic speech recognition is usually language specific. In this study, a language-independent approach is proposed. It uses models that are trained with Flemish speech, and it is applied to assess chronically hoarse German speakers. The research questions are here: is it possible to construct suitable acoustic features that generalize to other languages and a speech disorder, and is the generated model for intelligibility also suitable for specific subtypes of that disorder, i.e. functional and organic dysphonia? PATIENTS AND METHODS: 73 German-speaking persons with chronic hoarseness read the text 'Der Nordwind und die Sonne'. Perceptual intelligibility scores were used as ground truth during the training of an automatic model that converts speaker level acoustic measurements into intelligibility scores. Cross-validation is used to assess model performance. RESULTS: The interrater agreement for all patients (n = 73) and for the functional and organic dysphonia subgroups (n = 45 and n = 24) are r = 0.82, r = 0.83 and r = 0.75, respectively. The automatic assessment based on phonologically based acoustic models revealed correlations between perceptual and automatic intelligibility ratings of r = 0.79 (all patients), r = 0.78 (functional dysphonia) and r = 0.80 (organic dysphonia). CONCLUSION: The automatic, objective measurement of intelligibility is a valuable instrument in an evidence-based clinical practice.

Adult intensive care patients' perception of endotracheal tube-related discomforts: a prospective evaluation.

OBJECTIVE: This study was designed to investigate adult patients' perceptions of endotracheal tube (ETT)-related discomfort at 5 days and 2 months after discharge from the intensive care unit (ICU). METHODS: This prospective cohort study in 2 general ICUs included 250 intubated, mechanically ventilated adults admitted for more than 24 hours. Patients were interviewed 5 days and 2 months after discharge from the ICU about their ETT-related discomfort, using a modified Swedish ETT version of the ICU Stressful Experience Questionnaire that comprises 14 items. RESULTS: Of 116 patients describing their ETT experience during their ICU stay, 88% rated their discomfort as moderately to extremely stressful. At 2 months after discharge from the ICU, 23% (51/226) reported bothersome discomfort, vs. 46% (104/226) 5 days after discharge from the ICU, and 10 patients suffered from severe, persistent hoarseness. CONCLUSION: The incidence of bothersome subjective complaints after tracheal intubation in the intensive-care setting is high, and severe ETT-related problems may persist several months after extubation.

The relationship between depressive symptoms and Voice Handicap Index scores in laryngopharyngeal reflux.

OBJECTIVES/HYPOTHESIS: To determine if a relationship exists between depression and Voice Handicap Index (VHI) scores in patients with laryngopharyngeal reflux (LPR) disease. STUDY DESIGN: Retrospective analysis of prospectively collected data. METHODS: One hundred nineteen patients were prospectively evaluated with the VHI questionnaire and the Beck Depression Inventory Fast Screen (BDI-FS) survey. Patients with a pre-existing diagnosis of depression were excluded. RESULTS: Complete data was available for 36 patients with LPR and 53 controls. No significant differences existed between groups with respect to age, race, or gender. Mild depressive symptoms were identified in 9% of controls and 3% of LPR patients by BDI-FS screening (P = .4); no patients had moderate or severe depression symptoms. Compared to controls, patients with LPR had significantly higher mean scores for total VHI (16.2 vs. 6.6, P = .002), functional VHI (5.8 vs. 2.4, P = .02), and physical VHI (6.9 vs. 2.5, P = .008) domains. Mean scores for the VHI emotional domain (3.5 vs. 1.7, P = .2) and BDI-FS (0.2 vs. 0.8, P = .3) did not differ between patients with LPR and controls. For all participants, a positive correlation was found between BDI-FS score and VHI emotional domain score (r = 0.3, P = .008). CONCLUSIONS: Patients with LPR report poorer VHI functional and physical scores compared to controls; however, LPR symptoms do not result in significantly worse VHI emotional domain scores or depressive symptoms. There is a correlation between VHI emotional domain scores and BDI-FS scores. These data suggest that LPR patients with poor VHI emotional domain scores might benefit from screening for depressive symptoms.

Pathological likelihood index as a measurement of the degree of voice normality and perceived hoarseness.

A new index is introduced in this article to measure the degree of normality in the speech. The proposed parameter has demonstrated to be correlated with the perceived hoarseness, giving an indication of the degree of normality. The calculation of such a parameter is based on a statistical model developed to represent normal and pathological voices. The modeling is built around Gaussian mixture models and Mel frequency cepstral coefficients. The proposed index has been named pathological likelihood index (PLI). PLI is compared with other aperiodicity features (such as jitter and shimmer), and measurements sensitive to additive noise (such as harmonics-to-noise ratio (HNR), cepstrum-based HNR, normalized noise energy, and glottal-to-noise excitation ratio). The proposed parameter is revealed to be a good estimator of the presence of pathology, showing lower correlation with noise, frequency, and amplitude perturbation parameters than these classical features among them.

[Role of psychological factors in pathogenesis of disturbances of voice caused with vocal nodules]. / Rola czynników psychologicznych w patogenezie zaburzen glosu spowodowanych guzkami glosowymi.

INTRODUCTION: Hoarseness is most frequent complaint notified by ill in phoniatric outpatient clinics. Looking of causes notified of disturbances of voice often we ascertain in larynx existence of vocal nodules. Changes these come into being in consequence of excessive or irregular phonations. Single incident of disturbances of voice caused with oedema changes nascent of in consequence of inappropriate work with voice does not wake of our trouble, instead returns this of type of complaint provoke to other researches coexisting of etiological factors this diseases. AIM: Estimation of influence of individual personality trait of ill on formation of vocal nodules. MATERIAL AND METHODS: One examined 20 patients with vocal nodules classified to treatments operating and 20 without disturbances of voice. All patients were subjected to otolaryngological and stroboscopic examinations. Character created of voice one examined at help of scale GRBAS, instead influence of disturbances of voice on quality of life ill at help of test VHI. Psychological examinations one executed using questionnaire State-Trait-Anxiety-Inventory (STAI), questionnaire NEO-FFI and questionnaire of aggression Buss-Perry. RESULTS: Obtained results showed, that persons with returning vocal nodules, both during of research as in different situations everyday lives characterizes with higher level of fear and have greater inclination to worry oneself. Ill from groups examined in greater degree are extroverts, show greater activity and more are contagious socially in comparison to persons of comparative group. Attitude this in situations extorting rivalry will be able to be ruthless, are well organized guided, scrupulous and consistently endeavour to aim. CONCLUSIONS: Wanting efficiently to treat persons with returning vocal nodules we should subject to ill psychological examination and in once of ascertainment of irregularity to correct it, what at simultaneous correct treatment of organic changes should diminish frequency or to eliminate returns of disease. Skill psychological looks on patient by therapists treating disturbances of voice and speeches in case not large emotional instabilities probably would be able to improve results of treatment ill not only with functional disturbances of voice but also with disturbances of voice caused with organic changes in larynx.

Investigation into psychological correlates of patients with vocal nodules using the Symptom Checklist-90-Revision.

OBJECTIVE: The purpose of this study was to analyze the psychological characteristics of patients with vocal nodules and to establish the relationship between these characteristics and the development of vocal nodules. SETTING: A tertiary medical centre. DESIGN AND METHOD: The patient group consisted of 41 housewives with vocal nodules, and the control group consisted of 35 housewives who did not have any vocal pathology. The subjects completed questionnaires related to the voice disorder and the Symptom Checklist-90-Revision. OUTCOME MEASURES: The scores of the patient group with less than 1 year of symptom duration (acute) and more than 1 year of symptom duration (chronic) were also compared with those of the controls. RESULTS AND CONCLUSION: The total patient group differed statistically from the control group on seven neurotic dimensions (p < .001) and one psychotic dimension (p < .05). The acute group differed on two neurotic dimensions (p < .05). We suggest that the neurotic traits found in the acute group may play a role in the development of vocal nodules. The dimensions in which the total patient group differed significantly from the control group may indicate the changes that occur in the psychological characteristics following voice change. The collective results indicate that psychological characteristics play an important role in the pathogenesis of vocal nodules. Hence, greater attention should be given to the psychological and emotional aspects of patients for the treatment and prevention of vocal nodules.

Paradoxical vocal cord motion--a dangerous imitator of airway emergencies.

We report a case of stridor in a 32 year old woman. Initial laryngoscopy demonstrated adduction of the vocal cords on inspiration, which reverted to abduction on induction of general anaesthesia. The airway was structurally normal. The most likely diagnosis was paradoxical vocal cord motion, a condition in which psychological stress can precipitate respiratory symptoms and signs due to involuntary adduction of the vocal cords during inspiration. Its importance to the anaesthetist lies in its ability to masquerade as a serious airway or respiratory condition.

Laryngeal cancer patients: analysis of patient delay at different tumor stages.

BACKGROUND: The aim of this study was to determine the length of stages (appraisal, illness, behavioral, and scheduling) of patient delay in patients with head and neck cancer and to find out whether these delays were related to the stage of the disease at diagnosis. METHODS: Before treatment, 117 newly diagnosed patients with laryngeal cancer were interviewed about their prediagnostic period. To determine the length of the different stages of patient delay, patients were asked about their symptoms, attributions of symptoms, and reasons to postpone medical consultation. A questionnaire was sent to the general practitioner and to a close relative to verify their answers. RESULTS: There was no significant difference in the length of patient delay between early- (T1-T2) and advanced- stage (T3-T4) disease (9 vs 5 weeks; p = .07). Only tumor site was significantly associated with patient delay. The median total patient delays for glottic and supraglottic tumors were 10 and 4 weeks, respectively (p = .00). Hoarseness/voice change was the most commonly mentioned symptom. Patients attributed their symptom most frequently to a common cold/infection or had no idea about the cause. Medical attention was postponed because symptoms were interpreted as innocuous/benign or the symptom was thought not to be serious enough. The main reason to visit the general practitioner was persistent hoarseness. Behavioral and scheduling delays were of minor importance. CONCLUSIONS: Patient delay was significantly longer in cases of glottic cancer, but diagnosis at an early stage of the disease was more frequent among these patients than among patients with supraglottic cancer. Advanced supraglottic cancer probably has a late onset of symptoms. Thus, earlier intervention will probably not result in a significantly higher proportion of small supraglottic cancers being diagnosed.

Phonatory function following esophagectomy for esophageal cancer.

BACKGROUND/AIMS: Quality of life can be adversely affected in many patients who suffer phonation disorders such as hoarseness and dysphonia following esophagectomy. The present study investigated postoperative phonation disorders in 15 patients who underwent esophagectomy for esophageal cancer. METHODOLOGY: None of the patients had signs of hoarseness before or after surgery. Aerodynamic testing to assess phonatory function testing and laryngoscopy for observing laryngeal movements were performed before and after surgery. As a control, the same tests were conducted in 20 patients treated for gastric cancer by gastrectomy. RESULTS: For esophagectomy patients, mean postoperative flow rate was significantly increased and maximum postoperative phonation time was significantly decreased after operation. Laryngoscopy confirmed postoperative paralysis of left laryngeal movements and excessive adduction of the right, unaffected vocal cord during phonation in 8 of 15 esophagectomy patients, although hoarseness was not reported by any patient. No significant changes were observed for mean postoperative flow rate or maximum postoperative phonation time following surgery in gastrectomy patients. CONCLUSIONS: Surgical procedures in the vicinity of the recurrent laryngeal nerve appear to be the cause of postoperative phonation disorders in patients undergoing esophagectomy for esophageal cancer, and these disorders can occur in the absence of symptoms such as hoarseness and dysphonia.

[Validation of the German version of the Voice Handicap Index]. / Validierung des Voice Handicap Index (VHI) in der deutschen Fassung.

The voice handicap index (VHI) was developed in the United States for subjective evaluation of a voice disturbance by the patient. The translation into German has been applied for a German population of patients. It was validated by the examination of 316 adult patients, 221 female and 95 male. The reliability of the VHI rests on a high Cronbach's alpha (0.96). A factor analysis in order to structure the items yields four factors that can be interpreted as negative voice experience (factor 1-explaining 20.83% of the variance after rotation), lack of assertiveness (factor 2-18.82%), lack of vocal power (factor 3-12.84%), and negative emotionality (factor 4-11.01%). The mean VHI scores differ significantly from each other in different degrees of voice disturbance as estimated by the patients themselves. The voice handicap index is qualified as a diagnostic tool for German-speaking countries.

[The relationship between acoustic analysis and auditory assessment].

OBJECTIVE: To investigate the relationship between acoustic analysis and auditory assessment of hoarseness. METHOD: 24 normal and 154 cases of pathological voice were included in this research. They were divided into 4 groups with different hoarseness and were accepted acoustic analysis. The parameters were analyzed by SPSS statistical software. RESULT: There were significant difference on acoustical parameters among each group excluding no difference of the jitter between normal and light hoarseness. NNE and SNR were the major parameters in descriptive of hoarseness. There were good correlation between 5 parameters and hoarseness assessment. CONCLUSION: Acoustic analysis is a useful method in clinical application to assess hoarseness with objective and simple advantage.

Does hoarseness of voice from recurrent nerve paralysis after esophagectomy for carcinoma influence patient quality of life?

BACKGROUND: Recurrent laryngeal nerve injury caused by esophageal cancer surgery is worrisome but often temporary; it is unclear when and how the paralysis is resolved. Hoarseness of voice from vocal cord paralysis (VCP) can have detrimental effects on postoperative patients. The aims of this study were to clarify the progress of nerve paralysis related to difficulty in talking after surgery and to assess whether hoarseness influences patient quality of life. STUDY DESIGN: Between 1985 and 1996, 141 esophageal cancer patients undergoing a resection by the Akiyama procedure were cancer free 1 year after surgery. Among them, 51 patients with VCP on discharge from the hospital were retrospectively reviewed. Their VCPs, body weights, and pulmonary functions were examined yearly. They were given a questionnaire relating to the difficulty in talking 1 year after surgery. RESULTS: VCP on discharge spontaneously healed within 1 year of surgery in 21 patients (41.2%), with the mean duration of difficulty in talking 5.7 months. The remaining 30 patients had persistent VCP 1 year after surgery; 4 VCPs spontaneously healed approximately 2 years after surgery. Eleven of the 30 patients with persistent VCP, who complained of severe hoarseness at 1 year postoperatively from inability to close the glottis during exertion, showed debilitation in performance status, abilities to go up stairs, and swallowing. In the group of patients with severe hoarseness, the percentage of ideal body weight (90.6%+/-11.0%) preoperatively and pulmonary functions at 3 years postoperatively were deteriorated, resulting in 3 patients with repeated aspiration pneumonia. CONCLUSIONS: The inability to compensate for aspiration, presenting as severe hoarseness, may be dependent on the preoperative nutritional state of patients along with degree of vocal cord atrophy and a decrease in pulmonary support. Persistent nerve paralysis deteriorates quality of life until it is adequately treated.