Association between intrarenal venous flow from Doppler ultrasonography and acute kidney injury in patients with sepsis in critical care: a prospective, exploratory observational study.

BACKGROUND: Intrarenal venous flow (IRVF) patterns assessed using Doppler renal ultrasonography are real-time bedside visualizations of renal vein hemodynamics. Although this technique has the potential to detect renal congestion during sepsis resuscitation, there have been few studies on this method. We aimed to examine the relationship between IRVF patterns, clinical parameters, and outcomes in critically ill adult patients with sepsis. We hypothesized that discontinuous IRVF was associated with elevated central venous pressure (CVP) and subsequent acute kidney injury (AKI) or death. METHODS: We conducted a prospective observational study in two tertiary-care hospitals, enrolling adult patients with sepsis who stayed in the intensive care unit for at least 24 h, had central venous catheters placed, and received invasive mechanical ventilation. Renal ultrasonography was performed at a single time point at the bedside after sepsis resuscitation, and IRVF patterns (discontinuous vs. continuous) were confirmed by a blinded assessor. The primary outcome was CVP obtained at the time of renal ultrasonography. We also repeatedly assessed a composite of Kidney Disease Improving Global Outcomes of Stage 3 AKI or death over the course of a week as a secondary outcome. The association of IRVF patterns with CVP was examined using Student's t-test (primary analysis) and that with composite outcomes was assessed using a generalized estimating equation analysis, to account for intra-individual correlations. A sample size of 32 was set in order to detect a 5-mmHg difference in CVP between IRVF patterns. RESULTS: Of the 38 patients who met the eligibility criteria, 22 (57.9%) showed discontinuous IRVF patterns that suggested blunted renal venous flow. IRVF patterns were not associated with CVP (discontinuous flow group: mean 9.24 cm H2O [standard deviation: 3.19], continuous flow group: 10.65 cm H2O [standard deviation: 2.53], p = 0.154). By contrast, the composite outcome incidence was significantly higher in the discontinuous IRVF pattern group (odds ratio: 9.67; 95% confidence interval: 2.13-44.03, p = 0.003). CONCLUSIONS: IRVF patterns were not associated with CVP but were associated with subsequent AKI in critically ill adult patients with sepsis. IRVF may be useful for capturing renal congestion at the bedside that is related to clinical patient outcomes.

Mapping versatile QTL for soybean downy mildew resistance.

KEY MESSAGE: Three versatile QTL for soybean downy mildew resistance in Japan were detected using five RIL populations and confirmed using recombinant fixed pairs or a backcrossed line. Downy mildew reduces soybean seed quality and size. It is a problem in Japan, where 90% of soybean grown is used as food. In the USA, 33 downy mildew races have been reported, but race differentiation in Japan is unclear. To identify quantitative trait loci (QTL) for downy mildew resistance effective in the Kanto and Tohoku regions, we performed QTL analysis using five populations of recombinant inbred lines (RILs) originated from 'Natto-shoryu' × 'Tachinagaha' (NT), 'Natto-shoryu' × 'Suzumaru', 'Satonohohoemi' × 'Fukuibuki' (SF), 'Kinusayaka' × 'COL/Akita/2009/TARC/1,' and 'YR-82' × 'Harosoy' over a 4-year period (2014-2017). We evaluated spontaneously developed symptoms of the RILs and applied 112-233 polymorphic markers to each population. Out of 31 QTL detected, we found five on chromosome 3 in three populations and another five on chromosome 7 in three populations. Other QTL were detected in one population, nine of them in different years. In the NT population, two QTL were detected in a 3.0-Mb region on chromosome 7 and in an 8.1-Mb region on chromosome 18 by evaluating nine recombinant fixed pairs in both Kanto and Tohoku regions. In the SF population, a QTL on chromosome 8 was detected in both regions. This QTL was introduced into the 'Satonohohoemi' background by backcrossing, and its effect was confirmed in both regions. In summary, two QTL on chromosomes 7 and 18 from the NT population and one QTL on chromosome 8 from the SF population were confirmed to be effective in both Tohoku and Kanto regions.

Identification and dissection of single seed weight QTLs by analysis of seed yield components in soybean.

Single seed weight (SSW), or seed size, is a seed yield components (SYC) in soybean, and it is suggested that the genetic factors regulating SSW are involved in the control of other SYCs. The quantitative trait loci (QTLs) for SSW and their effects on the other SYCs were investigated using a recombinant inbred line population derived from typical small- and large-seeded cultivars that were cultivated in two different environments. QTL analysis detected four environmentally stable QTLs for SSW, two of which coincided with the defined loci, qSw17-1 and Ln. The effects of the other loci, qSw12-1 and qSw13-1, were confirmed by analyzing residual heterozygous line progenies derived from the recombinant population. These four QTL regions were also involved in the control of an additional SYC, namely the large-seeded allele at each locus that reduced either the number of pods per plant or the number of ovules per pod. These results suggest the presence of at least two different regulatory mechanisms for SSW. Isolation of genes responsible for these QTLs provides an important tool in the understanding and utilization of SSW diversity for soybean breeding.

Seed yield and its components of indeterminate and determinate lines in recombinant inbred lines of soybean.

The present study was conducted to evaluate the benefits of indeterminate growth habit in breeding to improve yield potential of Japanese soybean varieties, which exclusively have determinate growth habit. Two populations of recombinant inbred lines (RILs) derived from crosses between determinate Japanese cultivars and indeterminate US cultivars were grown in Akita and Kyoto, and seed weight per plant (SW) and its components were compared between indeterminate and determinate RILs. The difference of SW between the two growth habits in RILs varied depending on maturation time. The SW of early indeterminate lines was significantly higher than that of early determinate ones in Akita, but not in Kyoto. Among yield components, the number of seeds per pod was constantly larger in indeterminate lines than that in determinate ones irrespective of maturation time. The number of seeds per plant and the number of pods per plant of the indeterminate lines were greater than those of the determinate lines in early maturation in Akita. These results suggest that the indeterminate growth habit is an advantageous characteristic in breeding for high yield of early maturing soybean varieties in the Tohoku region.

[Pulmonary Arterioplasty with Autologous Pericardial Patch for Lung Cancer].

Three patients underwent left upper lobectomy with arterioplasty of left pulmonary artery trunk for lung cancer. For pulmonary arterioplasty, wide wedge resection and patch plasty with autologous pericardium was performed. No in-hospital death or no postoperative complications due to arterioplasty was encountered. The mean follow-up period was 3.6 years and long-term patency of the reconstructed pulmonary artery was confirmed by computed tomography in all patients.

A major and stable QTL associated with seed weight in soybean across multiple environments and genetic backgrounds.

KEY MESSAGE: We detected a QTL for single seed weight in soybean that was stable across multiple environments and genetic backgrounds with the use of two recombinant inbred line populations. Single seed weight (SSW) in soybean is a key determinant of both seed yield and the quality of soy food products, and it exhibits wide variation. SSW is under genetic control, but the molecular mechanisms of such control remain unclear. We have now investigated quantitative trait loci (QTLs) for SSW in soybean and have identified such a QTL that is stable across multiple environments and genetic backgrounds. Two populations of 225 and 250 recombinant inbred lines were developed from crosses between Japanese and US cultivars of soybean that differ in SSW by a factor of ~2, and these populations were grown in at least three different environments. A whole-genome panel comprising 304 simple sequence repeat (SSR) loci was applied to mapping in each population. We identified 15 significant QTLs for SSW dispersed among 11 chromosomes in the two populations. One QTL located between Sat_284 and Sat_292 on chromosome 17 was detected (3.6 < LOD < 14.1) in both populations grown in all environments. This QTL, tentatively designated qSw17-1, accounted for 9.4-20.9 % of phenotypic variation in SSW, with a dominant allele being associated with increased SSW. Given its substantial effect on SSW, qSw17-1 is an attractive target for positional cloning, and SSR markers closely associated with this locus may prove useful for marker-assisted selection for SSW control in soybean.

Chromosome-level genome assemblies for two quinoa inbred lines from northern and southern highlands of Altiplano where quinoa originated.

Quinoa is emerging as a key seed crop for global food security due to its ability to grow in marginal environments and its excellent nutritional properties. Because quinoa is partially allogamous, we have developed quinoa inbred lines necessary for molecular genetic analysis. Our comprehensive genomic analysis showed that the quinoa inbred lines fall into three genetic subpopulations: northern highland, southern highland, and lowland. Lowland and highland quinoa are the same species, but have very different genotypes and phenotypes. Lowland quinoa has relatively small grains and a darker grain color, and is widely tested and grown around the world. In contrast, the white, large-grained highland quinoa is grown in the Andean highlands, including the region where quinoa originated, and is exported worldwide as high-quality quinoa. Recently, we have shown that viral vectors can be used to regulate endogenous genes in quinoa, paving the way for functional genomics to reveal the diversity of quinoa. However, although a high-quality assembly has recently been reported for a lowland quinoa line, genomic resources of the quality required for functional genomics are not available for highland quinoa lines. Here we present high-quality chromosome-level genome assemblies for two highland inbred quinoa lines, J075 representing the northern highland line and J100 representing the southern highland line, using PacBio HiFi sequencing and dpMIG-seq. In addition, we demonstrate the importance of verifying and correcting reference-based scaffold assembly with other approaches such as linkage maps. The assembled genome sizes of J075 and J100 are 1.29 and 1.32 Gb, with contigs N50 of 66.3 and 12.6 Mb, and scaffold N50 of 71.2 and 70.6 Mb, respectively, comprising 18 pseudochromosomes. The repetitive sequences of J075 and J100 represent 72.6% and 71.5% of the genome, the majority of which are long terminal repeats, representing 44.0% and 42.7% of the genome, respectively. The de novo assembled genomes of J075 and J100 were predicted to contain 65,303 and 64,945 protein-coding genes, respectively. The high quality genomes of these highland quinoa lines will facilitate quinoa functional genomics research on quinoa and contribute to the identification of key genes involved in environmental adaptation and quinoa domestication.

Phosphate starvation response precedes abscisic acid response under progressive mild drought in plants.

Drought severely damages crop production, even under conditions so mild that the leaves show no signs of wilting. However, it is unclear how field-grown plants respond to mild drought. Here, we show through six years of field trials that ridges are a useful experimental tool to mimic mild drought stress in the field. Mild drought reduces inorganic phosphate levels in the leaves to activate the phosphate starvation response (PSR) in soybean plants in the field. Using Arabidopsis thaliana and its mutant plants grown in pots under controlled environments, we demonstrate that PSR occurs before abscisic acid response under progressive mild drought and that PSR plays a crucial role in plant growth under mild drought. Our observations in the field and laboratory using model crop and experimental plants provide insight into the molecular response to mild drought in field-grown plants and the relationship between nutrition and drought stress response.

Genome sequencing reveals the genetic architecture of heterostyly and domestication history of common buckwheat.

Common buckwheat, Fagopyrum esculentum, is an orphan crop domesticated in southwest China that exhibits heterostylous self-incompatibility. Here we present chromosome-scale assemblies of a self-compatible F. esculentum accession and a self-compatible wild relative, Fagopyrum homotropicum, together with the resequencing of 104 wild and cultivated F. esculentum accessions. Using these genomic data, we report the roles of transposable elements and whole-genome duplications in the evolution of Fagopyrum. In addition, we show that (1) the breakdown of heterostyly occurs through the disruption of a hemizygous gene jointly regulating the style length and female compatibility and (2) southeast Tibet was involved in common buckwheat domestication. Moreover, we obtained mutants conferring the waxy phenotype for the first time in buckwheat. These findings demonstrate the utility of our F. esculentum assembly as a reference genome and promise to accelerate buckwheat research and breeding.

[Reduction of angialgia during peripheral administration of oxaliplatin mixed with dexamethasone].

Seven patients who had been receiving capecitabine+oxaliplatin±bevacizumab(CapeOX±BV)therapy at our hospital between February 2010 and March 2011, had complained of angialgia during oxaliplatin(L-OHP)administration. Therefore, 3. 3 mg of dexamethasone(DEX)was added to their infusion solution. The patients were then asked to rate their angialgia severity using a numerical rating scale(NRS), when L-OHP in a 5% dextrose solution was administered with or without DEX. By changing the L-OHP in 5% dextrose solution without DEX to the solution containing 3. 3 mg of DEX, the mean NRS was improved to 2. 4 from 7. 1. These findings indicate that L-OHP in 5% dextrose solution mixed with 3. 3 mg of DEX seems to be useful in reducing angialgia during peripheral administration of L-OHP.

Association of intranasal desmopressin therapy with overcorrection of severe hyponatremia: A retrospective, propensity score-based, single-center cohort study.

PURPOSE: Severe hyponatremia, defined as serum sodium concentration ([sNa]) ≤ 120 mEq/L, requires aggressive treatment to prevent potentially fatal cerebral edema, seizures, and other sequelae, but overcorrection can also result in life-threatening cerebral hemorrhage and demyelination. We compared the safety and efficacy of nasal desmopressin to conventional management for the prevention of [sNa] overcorrection. MATERIAL AND METHODS: This retrospective analysis compared 47 patients treated with desmopressin to 17 patients treated conventionally at a university hospital ICU in Japan between 2013 and 2018 using propensity score-based approaches. The primary outcome was safe [sNa] correction, defined as a ≤ 8 mEq/L difference between baseline and follow-up [sNa] at any time within 24h of diagnosis. RESULTS: The 24-h safe correction rate was significantly greater in the desmopressin group than the conventional treatment group (68% [32/47] vs. 41% [7/17], P = 0.039), and dose-response analysis indicated a positive association between cumulative 24-h desmopressin dose and safe correction at 24 h (P = 0.003). Few overcorrections precluded reliable assessment at 48 h. Exacerbation of hyponatremia was comparable in the two treatment groups. CONCLUSIONS: Intranasal desmopressin therapy increased the safe correction of severe hyponatremia. Large prospective trials are warranted to confirm this result.

Virus-Mediated Transient Expression Techniques Enable Functional Genomics Studies and Modulations of Betalain Biosynthesis and Plant Height in Quinoa.

Quinoa (Chenopodium quinoa), native to the Andean region of South America, has been recognized as a potentially important crop in terms of global food and nutrition security since it can thrive in harsh environments and has an excellent nutritional profile. Even though challenges of analyzing the complex and heterogeneous allotetraploid genome of quinoa have recently been overcome, with the whole genome-sequencing of quinoa and the creation of genotyped inbred lines, the lack of technology to analyze gene function in planta is a major limiting factor in quinoa research. Here, we demonstrate that two virus-mediated transient expression techniques, virus-induced gene silencing (VIGS) and virus-mediated overexpression (VOX), can be used in quinoa. We show that apple latent spherical virus (ALSV) can induce gene silencing of quinoa phytoene desaturase (CqPDS1) in a broad range of quinoa inbred lines derived from the northern and southern highland and lowland sub-populations. In addition, we show that ALSV can be used as a VOX vector in roots. Our data also indicate that silencing a quinoa 3,4-dihydroxyphenylalanine 4,5-dioxygenase gene (CqDODA1) or a cytochrome P450 enzyme gene (CqCYP76AD1) inhibits betalain production and that knockdown of a reduced-height gene homolog (CqRHT1) causes an overgrowth phenotype in quinoa. Moreover, we show that ALSV can be transmitted to the progeny of quinoa plants. Thus, our findings enable functional genomics in quinoa, ushering in a new era of quinoa research.

Occurrence and incidence rate of peripheral intravascular catheter-related phlebitis and complications in critically ill patients: a prospective cohort study (AMOR-VENUS study).

BACKGROUND: The lack of precise information on the epidemiology of peripheral intravascular catheter (PIVC)-related phlebitis and complications in critically ill patients results in the absence of appropriate preventive measures. Therefore, we aimed to describe the epidemiology of the use of PIVCs and the incidence/occurrence of phlebitis and complications in the intensive care unit (ICU). METHODS: This prospective multicenter cohort study was conducted in 23 ICUs in Japan. All consecutive patients aged ≥ 18 years admitted to the ICU were enrolled. PIVCs inserted prior to ICU admission and those newly inserted after ICU admission were included in the analysis. Characteristics of the ICU, patients, and PIVCs were recorded. The primary and secondary outcomes were the occurrence and incidence rate of PIVC-related phlebitis and complications (catheter-related blood stream infection [CRBSI] and catheter failure) during the ICU stay. RESULTS: We included 2741 patients and 7118 PIVCs, of which 48.2% were inserted in the ICU. PIVC-related phlebitis occurred in 7.5% (95% confidence interval [CI] 6.9-8.2%) of catheters (3.3 cases / 100 catheter-days) and 12.9% (95% CI 11.7-14.2%) of patients (6.3 cases / 100 catheter-days). Most PIVCs were removed immediately after diagnosis of phlebitis (71.9%). Grade 1 was the most common phlebitis (72.6%), while grade 4 was the least common (1.5%). The incidence rate of CRBSI was 0.8% (95% CI 0.4-1.2%). In cases of catheter failure, the proportion and incidence rate per 100 intravenous catheter-days of catheter failure were 21% (95% CI 20.0-21.9%) and 9.1 (95% CI 8.7-10.0), respectively. CONCLUSION: PIVC-related phlebitis and complications were common in critically ill patients. The results suggest the importance of preventing PIVC-related complications, even in critically ill patients. TRIAL REGISTRATION: UMIN-CTR, the Japanese clinical trial registry (registration number: UMIN000028019 , July 1, 2017).

Two novel quantitative trait loci affecting the variation in leaf photosynthetic capacity among soybeans.

There is a large variation in CO2 assimilation rate per unit of leaf area (A) within or among crop species, which can be exploited to improve A by elucidating the mechanisms underlying such variation. The objective of the present study is to elucidate the genetic factors affecting the variation in leaf photosynthetic capacity among soybeans. Here, we conducted field experiments over three years, using Enrei, a leading variety in Japan, Peking, a landrace from China and the chromosome segment substitution lines derived from their progenies. The gas exchange measurements were conducted to evaluate A among soybean. Peking showed higher A than Enrei after the flowering in all the years. The genetic analysis identified two novel quantitative trait loci (QTLs) related to variation in A, which were located on chromosome 13 (qLPC13) and 20 (qLPC20). The Peking allele at qLPC13 increased A by 8.3 % in the Enrei genetic background, while the Peking allele at qLPC20 decreased A by 15.3 %. The present study is the first report on QTLs affecting a genotypic variation in leaf photosynthetic capacity among field-grown soybeans. The identification of the causal genes in these QTLs can provide a novel strategy to enhance leaf photosynthetic capacity with soybean breeding.

Polymorphisms in the lymphotoxin alpha gene and the risk of ischemic stroke in the Japanese population. The Fukuoka Stroke Registry and the Hisayama Study.

BACKGROUND AND PURPOSE: Lymphotoxin alpha (LTA), one of the tumor necrosis factor family proteins, is an important proinflammatory cytokine and appears to play a putative role in the inflammatory process of atherosclerosis. Recent genetic studies have suggested that variations in the gene encoding LTA, which affect its expression and biological function, may contribute to the development of vascular diseases. We conducted a case-control study to clarify the association of LTA gene polymorphisms with ischemic stroke in a large Japanese population. METHODS: Genotyping for LTA A252G and C804A polymorphisms was achieved by a rapid-cycle polymerase chain reaction and melting curve analysis using fluorescent probes in 1,044 incident cases of ischemic stroke recruited from the Fukuoka Stroke Registry and 1,044 age- and sex-matched control subjects recruited from the Hisayama Study. RESULTS: The overall distribution of allele and genotype for each polymorphism was similar between stroke patients and control subjects. The allele frequencies of 252G and 804A were slightly lower in stroke patients than in control subjects; however, conditional logistic regression analysis adjusted for potential risk factors found no association between the risk of ischemic stroke and either polymorphism. In terms of stroke subtype, we also found no association of these polymorphisms with any subtypes of ischemic stroke. CONCLUSIONS: Neither the A252G nor C804A polymorphism of the LTA gene was associated with stroke overall and any subtypes of ischemic stroke in the Japanese population.

A case of vitamin B12 deficiency with involuntary movements and bilateral basal ganglia lesions.

An 86-year-old woman with a one-year history of dementia was admitted to our hospital complaining of loss of appetite, hallucinations, and disturbance of consciousness. She gradually presented with chorea-like involuntary movements of the extremities. Diffusion-weighted magnetic resonance imaging (MRI) showed bilateral symmetrical hyperintense signals in the basal ganglia. The serum vitamin B12 level was below the lower detection limit of 50 pg/ml. The homocysteine level was markedly elevated at 115.8 nmol/ml. Anti-intrinsic factor and anti-parietal cell antibody tests were positive. Gastrointestinal endoscopy revealed atrophic gastritis. The patient was diagnosed with encephalopathy due to vitamin B12 deficiency caused by pernicious anemia. Involuntary movements and MRI abnormalities improved with parenteral vitamin B12 supplementation. Bilateral basal ganglia lesions are rare manifestations of adult vitamin B12 deficiency. The present case is considered valuable in identifying the pathophysiology of involuntary movement due to vitamin B12 deficiency.

Stroke in patients on maintenance hemodialysis: a 22-year single-center study.

BACKGROUND: Few studies have reported the detailed clinical features of stroke in patients with end-stage renal disease. We examined the frequency of the subtypes, mechanism, and outcome of stroke in patients receiving hemodialysis (HD). METHODS: We studied 151 consecutive patients who developed an acute stroke among the maintenance HD population in our kidney center during 22 years, divided into the initial 17-year (n = 61) and the more recent 5-year (n = 90) groups. For purposes of comparison, we also studied 1,017 stroke patients with normal renal function. RESULTS: Stroke patients receiving HD were younger (age, 64 +/- 10 versus 67 +/- 13 years; P < 0.02) and more frequently had hypertension (87% versus 43%; P < 0.0001) and diabetes (53% versus 23%; P < 0.0001) compared with stroke patients with normal renal function. In the initial HD group, brain hemorrhage was the major subtype of stroke (52%), whereas in the more recent group, brain infarction (BI) replaced hemorrhage as the leading subtype (68%; P < 0.005). In patients with BI, large-artery atherosclerosis was more prevalent in the more recent group than in the initial HD group (33% versus 12%; P < 0.05). A vertebrobasilar territory infarct was more prevalent for HD patients than for those with normal renal function (48% versus 33%; P < 0.05). BI (especially large-artery atherosclerosis and cardioembolism) occurred more frequently during or less than 30 minutes after the dialysis procedure (34%) than brain hemorrhage (19%; P < 0.05). Receiving HD was an independent indicator for poor functional outcome and mortality after stroke. CONCLUSION: In our maintenance HD population, stroke showed several unique characteristics compared with the control population, including a predominance of vertebrobasilar arterial territory infarcts. The dialysis procedure itself seems to be associated more frequently with ischemic rather than hemorrhagic strokes.

Transcranial color-coded sonography for vertebrobasilar disorders in end-stage renal disease.

Because vertebrobasilar arterial disorders seem to be common in patients with end-stage renal disease, a neuroradiological evaluation of vertebrobasilar circulation is necessary for patients with possible vertebrobasilar insufficiency. In three patients on maintenance hemodialysis, contrast-enhanced transcranial color-coded real-time sonography (TCCS) through a suboccipital window delineated occlusion of bilateral vertebral arteries with reversal of the basilar artery, reversal of the left vertebral artery mimicking left subclavian steal phenomenon, and dolichoectasia of the basilar artery and bilateral vertebral arteries with signals of turbulent flow. TCCS has several advantages over computed tomographic angiography and magnetic resonance angiography, including the direction of blood flow, handy performance even during hemodialysis, and contrast agent free from nephrotoxicity. Thus, TCCS is useful in the evaluation of intracranial circulation in patients with end-stage renal disease.

Hypertensive encephalopathy extending into the whole brainstem and deep structures.

In patients with hypertensive encephalopathy, brain edema is frequently distributed in the parieto-occipital white matter. We report a patient with high arterial blood pressure of over 300/160 mmHg on admission, who had extensive MRI-documented reversible lesions throughout the whole brain, including the brainstem, thalami, basal ganglia, and cerebellum. Extraordinarily severe acceleration of hypertension may be essential for the breakdown of autoregulation in the deep structures, especially in the brainstem including medulla.

Bilateral deafness as a prodromal symptom of basilar artery occlusion.

Bilateral deafness is a rare but possible symptom for ischemia of the vertebrobasilar system, primarily derived from occlusion of anterior inferior cerebellar arteries or their branches. Patients 1 and 2 developed sudden bilateral deafness, soon followed by coma. The proximal segment of the basilar artery was occluded due to atherothrombosis in Patient 1 and arterial dissection in Patient 2. Thrombolytic therapy failed to recanalize the basilar arterial flow. Both patients died of extensive infarction in the vertebrobasilar arterial territory. Sudden bilateral deafness can be a warning sign of imminent brainstem ischemia by occlusion of the basilar artery regardless of age. Prompt and intensive management for stroke is needed for patients with sudden bilateral deafness.