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RESUMEN Objetivo: Estudiar la capacidad discriminativa de hipercatabolismo proteico grave del índice urea/creatinina en orina aislada en pacientes críticos ventilados. Metodos: Estudio prospectivo, observacional. Incluyó 52 pacientes sin insuficiencia renal. Variables: nitrógeno urinario total estimado a partir de la urea en orina de 24 horas al segundo (T1) y cuarto día (T2) e índice urea/creatinina en orina aislada previo a la recolección de orina de 24 horas. Resultados: Presentaron hipercatabolismo proteico grave (nitrógeno urinario total estimado > 15g) 14 pacientes (26,9%) en T1 y 29 (55,7%) en T2. El 84% de los pacientes presentaron bajo riesgo nutricional por la escala Nutrition Risk in the Critically Ill. En el segundo día, la correlación de Pearson del nitrógeno urinario total estimado con el índice urea/creatinina fue: 0,272 (p = 0,051) y en el cuarto día: 0,276 (p = 0,048). El índice urea/creatinina al cuarto día, tuvo una tendencia a mayor discriminación del hipercatabolismo proteico grave que el Acute Physiology and Chronic Health Evaluation II y Nutrition Risk in the Critically Ill (AUC 0,741 versus 0,669 y 0,656, IC95%: 0,602 - 0,880; 0,519 - 0,818 y 0,506 - 0,806 respectivamente). El valor de corte optimo del índice urea/creatinina para diagnóstico de hipercatabolismo proteico grave fue de 16,15 con una sensibilidad de 79,31% (IC95%: 59,74 - 91,29), especificidad de 60,87% (IC95%: 38,78 - 79,53), valor predictivo positivo 71,88% (IC95%: 53,02 - 85,60), valor predictivo negativo 70,0% (IC95%: 45,67 - 87,18), LR (+) 2,03 (IC95%: 1,18 - 3,49) y LR (-) 0,34 (IC95%: 0,16 - 0,74). Conclusión: El índice urea/creatinina realizado al cuarto día tiene un discreto valor para estimar el hipercatabolismo proteico grave por nitrógeno urinario total y no reemplaza al mismo en pacientes críticos ventilados sin falla renal. Por su razonable sensibilidad podría ser utilizado como cribado para identificar a quien tomar la muestra de orina de 24 horas.
ABSTRACT Objective: To study the ability of the urea/creatinine index to identify severe protein catabolism from the isolated urine of critically ventilated patients. Methods: This was a prospective, observational study. It included 52 patients without kidney failure. Variables: total urinary nitrogen estimated from the urea in 24-hour urine on the second (T1) and fourth days (T2) and urea/creatinine index in isolated urine before 24-hour urine collection. Results: Severe protein hypercatabolism (estimated total urinary nitrogen > 15g) was present in 14 patients (26.9%) at T1 and in 29 (55.7%) at T2. Eighty-four percent of patients had low nutritional risk by the Nutrition Risk in the Critically Ill score. At T1, the Pearson correlation between the estimated total urinary nitrogen and the urea/creatinine index was 0.272 (p = 0.051), and at T2 it was 0.276 (p = 0.048). The urea/creatinine index at T2 had a tendency to better discriminate severe protein hypercatabolism than Acute Physiology and Chronic Health Evaluation II and Nutrition Risk in the Critically Ill (AUC 0.741 versus 0.669 and 0.656, 95%CI: 0.602 - 0.880; 0.519 - 0.818 and 0.506 - 0.806, respectively). The optimal cutoff value of the urea/creatinine index for the diagnosis of severe protein hypercatabolism was 16.15, with a sensitivity of 79.31% (95%CI: 59.74 - 91.29), specificity of 60.87% (95%CI: 38.78 - 79.53), positive predictive value 71.88% (95%CI: 53.02 - 85.60), negative predictive value 70.0% (95%CI: 45.67 - 87.18), LR (+) 2.03 (95%CI: 1.18 - 3.49), and LR (-) 0.34 (95%CI: 0.16 - 0.74). Conclusion: The urea/creatinine index measured on the fourth day has a certain ability to estimate severe protein hypercatabolism (as defined by estimated total urinary nitrogen) but does not replace total urinary nitrogen in critically ventilated patients without kidney failure. Due to its reasonable sensitivity, it could be used as a screen to identify which patients to take a 24-hour urine sample from.
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Humanos , Respiração Artificial , Estado Terminal , Ureia , Estudos Prospectivos , CreatininaRESUMO
Background Retinitis pigmentosa (RP) is one of the causes of congenital blindness.It is well known that the degeneration process of rod cells is difficult to detect in RP.Retinal degeneration 12 (rd12) mice is a new,spontaneously arising mouse model for human Leber congenital amaurosis (LCA),and it is helpful for us to explore the pathogenesis and determine the treating target of RP.Objective This study was to investigate the natural disease process of short-length sensitive cone cells in rd12 mice,a LCA Rpe65rd12 (B6 [A]-Rpe65rd12/J) mouse.Methods The rd12 mice at postnatal (P) 14,P21,P35 and P90 were selected (5 mice for each),and the wild-type C57BL/6J (B6) mice with matched ages were included as controls.Photopic full-field electroretinogram (ERG) was recorded with Roland Q450SC UV visual physiology instrument.Cone response was recorded using single white light-emitting diode (LED) stimulation with the flash intensity of 1.00 cds/m2 and 1.96 cds/m2,and short wave-length sensitive cone response was recorded using ultraviolet light ([363 ±6] nm) stimulation with the flash intensity of 2.0 mWs/m2 and 3.0 mW/m2.The mice were sacrificed and retinal whole-mounts were prepared.The distribution and number of cone cells and UV-sensitive cone cells were detected by FITC-peanut agglutinin (FITC-PNA) and Cy3 immunofluorescence stainning,respectively.Results In P14 rd12 mice,the ERG responses of overall cone cells presented the negative waveform and the latency was delayed,and UV-sensitive cone response was unrecordable.The b-wave amplitude of overall cone cells reduced by 75％ in P21 rd12 mice compared with wild-type B6 mice,and the mean latency of b-wave in the P21 rd12 mice was significantly longer than that in the wild-type B6 mice ([102.80± 11.39] ms vs.[43.40± 5.60] ms) (t =-8.106,P =0.001).The mean b-wave amplitudes of U Vsensitive cone cells were (59.60± 36.00),(82.40± 12.22) and (68.43 ± 17.63) μV in the wild-type B6 mice,andthose in the rd12 mice were unrecordable.Immunofluorescence showed that a lager number of cone cells with green fluorescence were seen,and the expression of opsin with red fluorescence was displayed in the UV-sensitive cone cells of nasal lateral on retinal ventral side in P14 wild-type B6 mice;while only a few opsin positive-response cells were seen in P14,P21 and P35 rd12 mice.Conclusions In rd12 mice,the functional abnormality and quantitative reduction of cone cells appear in the early postnatal days,and the loss of UV-sensitive cone cells is earlier and more obvious.
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Background Studies showed that microRNA (miR)-375 suppresses the growth,apoptosis,migration and adhesion of tumor cells,and it plays a regulation to the changes of vascular endothelial growth factor (VEGF) in tumor tissue to arrest neovascularization.However,whether miR-375 intervenes the formation of new blood vessel in eyes is unelucidated.Objective This study was to explore the effects of miR-375 on human retinal capillary endothelial cells (HRCECs) function induced by hypoxia.Methods HRCECs were cultured using IMDM and divided into normal control group,CoCl2 model group,CoCl2 +miR-375 mimic group,CoCl2 +miR-375 mimic control group,CoCl2+miR-375 inhibitor group and CoCl2 +miR-375 inhibitor control group,and hypoxia cell models were created by adding 200 μmol/L CoCl2.MiR-375 and frizzled 4 (FZD4) small interfering RNA (siRNA) were transfected into the cells by 50 nmol/L miRNA lipidosome for 48 hours.The proliferation of the cells was detected by MTT assay;migrated number of the cells was examined by Transwell chamber assay;ELISA was employed to detect the concentrations of VEGF and VE-cadherin in the medium;the expression of β-catenin,cyclinD1,matrix metalloproteinase-2 (MMP2) and VEGF proteins were analyzed by Western blot;tube length of vessel formation was evaluated by Matrigel assay.Cultured cells were divided into normal control group,CoCl2 model group,CoCl2 +mock group and CoCl2 + FZD4 siRNA group,the relative expression of FZD4,a miR-375 targeted gene,was detected by luciferase reporter.Results The relative expression of miR-375 mRNA was significantly increased in the CoCl2 +miR-375 mimic group compared with the CoCl2 + miR-375 mimic control group and reduced in the CoCo2 + miR-375 inhibitor group compared with the CoCo2 + miR-375 inhibitor control group (t =-19.237,8.764,both at P＜0.01),with a higher transfected efficacy for miR-375.The cell proliferative fold,migrated cell number,VEGF and VE-Cadherin contents in the medium and the tube length were significantly different among the CoCl2 model group,CoCl2 +miR-375 mimic group,CoCl2 +miR-375 mimic control group,CoCl2 +miR-375 inhibitor group and CoCl2 +miR-375 inhibitor control group (F =24.324,26.776,14.113,19.225,15.040,all at P＜0.001),and those in the CoCl2 +miR-375 mimic group were evidently reduced in the CoCl2 +miR-375 mimic group compared with the CoCl2 +miR-375 mimic control group,while those in the CoCl2 +miR-375 inhibitor group were considerably elevated in comparison with the CoCl2 +miR-375 inhibitor control group (all at P＜0.01).The expressions of β3-catenin,cyclinD1,MMP2 and VEGF protein were significantly different among the normal control group,CoCl2 model group,CoCl2 +miR-375 mimic group,CoCl2+miR-375 mimic control group,CoCl2 +miR-375 inhibitor group and CoCl2 +miR-375 inhibitor control group (F=11.753,13.283,16.770,10.334,all at P＜0.001).In addition,the cell proliferative fold,migrated cell number and the tube length were significantly increased in the CoCl2 model group and CoCl2+mock group,and those in the CoCl2+FZD4 siRNA group were decreased in comparison with the CoCl2 +mock group (all at P＜0.05).Conclusions MiR-375 inhibits the growth,migration and tube formation ability of HRCECs in hypoxic status probably by regulating the activation of Wnt pathway via directly targeting FZD4.
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Background Idiopathic orbital inflammatory pseudotumor (IOIP) is a commom orbital disease,with serious eye symptoms and replase tendency,and its pathogenesis is still unclear.Nuclear factor-κB (NF-κB)-related proteins participate in many important pathophysiological process,however,whether NF-κB plays a role in the IOIP process is worthy of attention.Objective This study was to explore the roles of NF-κB pathway in IOIP pathogenesis.Methods Twenty-four IOIP specimens were collected during surgery in Beijing Tongren Hospital from September 2010 to May 2016.The histopathological characteristics of IOIP were examined by hematoxylin and eosin staining.The expression and location of NF-κB/p65,p-p65,p50 and inhibitor of κB (IκB-ot) were detected by immunohistochemistry and verified by immunocytochemistry and Western blot assay.Results The histopathological features of IOIP were numerous small lymphocyte infiltraion and fibrous tissue proliferation,and a lot of epithelioid cells were seen in lacrimal gland-involved specimens.NF-κB/p65 was positively expressed in the cytoplasm of all 24 specimens and the nucleus in 15 specimens with the expressing rate of 62.5％.p50 was expressed in the cytoplasm in 22 specimens with the expressing rate of 91.7％ and in the nucleus in 17 specimens with the expressing rate of 70.8％.The positive expression of p-p65 was found in 22 specimens with the expressing rate of 91.7％,and IκB-α was expressed in the cytoplasm of 11 specimens with the expressing rate of 45.8％.These results were confirmed by immunocytochemistry and Western blot assay.Conclusions NF-κB pathway is activiated during IOIP process,and NF-κB pathway may be involved in the pathogenesis of IOIP.
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Background Age-related cataract is a common cause of blindness.However,its cause and pathogenic mechanism have not been fully understood.Recent studies revealed that aquaporin 1 (AQP1) and AQP0 are closely related to the pathogenesis of cataract.Objective This study was to investigate the differential distribution and expression of AQP0 and AQP1 in lenses with age-related cataract and explore its effect on pathogenesis of age-related cataract.Methods Seventeen anterior capsular membrane samples and nucleus samples of lenses were collected from age-related cataract patients during the small incision nonphacoemulsification cataract extraction,and 6 normal lens samples were obtained from health donors in the First Affiliated Hospital of Fujian Medical University.The expression and distribution of AQP1 and AQP0 in the lenses were detected by immunohistochemistry,and the relative expression levels of AQP1 and AQP0 proteins in the lenses were assayed by using Western blot assay.This study protocol was approved by Ethic Committee of this hospital,and written informed consent was obtained from each patient.Results Immunohistochemistry showed that in the normal lenses,AQP1 expressed mainly in LECs;while AQP0 primarily expressed in fiber cells of the lens cortex and nucleus.The relative expression levels of AQP1 and AQP0 in the lenses with age-related cataract (absorbance) were 0.223±0.008 and 0.118±0.015,which were significantly lower than 0.246±0.007 and 0.149±0.007 in the normal lenses (t =-4.508,-3.291,both at P＜0.01).Western blot revealed that the relative expression levels of AQP1 and AQP0 in the lenses with age-related cataract (absorbance) were 0.663 ± 0.012 and 0.599 ± 0.015,which were significantly reduced in comparison with 0.844±0.041 and 0.955 ±0.064 in the normal lenses (t =-7.492,P＜0.05;t =-9.570,P＜0.01).Conclusions AQP1 and AQP0 distribute in different sites of lenses.The expressions of AQP1 and AQP0 are obviously down-regulated in lenses with age-related cataract,suggesting that AQP1 and AQP0 probably play different roles in the pathogenesis of age-related cataract.
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Background Pluripotent stem cell-derived retinal pigment epithelial (RPE) cells holds great promise for the treatment of age-related macular degeneration (AMD) and retinitis pigmentosa (RP),but the poor induction efficiency and the according high cost of RPE differentiation hindere its clinical applications.Curcumin is proved to have a promoting effect on the induced differentiation of embryonic stem cells (ESCs).However,the mechanism of curcumin on differentiation of human ESCs into RPE-like cells remains unclear.Objective This study aimed to explore the underlying molecular mechanism of curcumin on directed differentiation of human ESCs into RPE-like cells.Methods Human ESCs strains were cultured in the Matrigel-coated 6-well plate with mTeSRTM 1 medium until over-confluence,and basic fibroblast growth factor was withdrawn there after to induce automatic differentiation.Curcumin at the final concentration 1 μmol/L was added in the first day of differentiation for 24 hours,and the cells without curcumin in the medium served as the control group.Total RNA and protein were extracted at 3 weeks and 5 weeks after induction.RT-PCR,Western blot and immunofluorescence were performed to examine the expressions of the biomarks of stem cells and RPE cells as well as Wnt/β-catenin signaling pathway components.The endocytosis of polystyrene microsphere by induced RPE (iRPE) cells was investigated to verify their function of phagocytosis which features RPE cells.Results Pigmented cells were found from 3 weeks through 5 weeks after induction in the curcumin group,but only less pigmented cells were seen in the fifth week after induction in the control group.In the third and fifth week after induction,the relative expression levels of NANOG mRNA in the iRPE cells were significantly lower than those in the control group (t =13.086,P =0.022;t =34.186,P =0.004),and the relative expression levels of Pax6,RX,CRALBP and RPE65 mRNA were higher in the curcumin group than those of the control group (all at P＜0.01).Western blot assay showed that the expressing bands for CRALBP,RPE65 and MITF enhanced in iRPE cells with a similar appearance in human RPE cells.However,these expressions were all absent in human ESCs.Immunofluorescence staining showed the positive expressions of Pax6,MITF and ZO-1 in cytoplasm of iRPE cells in the curcumin group with a purified efficacy 100％.The fluorescence dye-doped polystyrene microspheres in cytoplasm were obvious in the iRPE cells like positive controls,but the polystyrene microsphere was absent in the negative controls.From 3 weeks through 5 weeks after induced,the relative expression levels of Lef1,MYC and TCF7 mRNA (the dwnstream target genes of Wnt signaling pathway),FZD3 mRNA (Wnt receptor),Wnt2B mRNA (Wnt ligand) and Wnt7B mRNA were significantly reduced in the curcumin group compared with the control group (all at P＜0.01).Conclusions Curcumin promotes the differentiation of human ESCs into RPE-like cells by stimulating the activation of Wnt signaling pathway,and therefore accelerate the differentiation and mature of iRPE cells.
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Objective To observe the effect of paeoniflorin on insulin resistance in rats fed with high-fat diet and to investigate the possible mechanisms.Methods Male Sprague Dawley (SD) rats were randomized into 4 groups:normal control,high-fat diet,high-dosage paeoniflorin (HDP group),and lowdosage paeoniflorin (LDP group).The control group was fed with ordinary diet,while the others with highfat diet,paeoniflorin intervention groups were given low-or high-dosage paeoniflorin by intraperitoneal injection.After 6 weeks,fasting serum triacylglycerol (TG),total cholesterol (TC),free fatty acids (FFA),fasting blood glucose (FBG),and insulin were determined.Insulin sensitivity index (ISI) were calculated and then the animals were sacrificed to acquire epididymal fat mass.The tumor necrosis factor alpha (TNFα) and glucose transporter 4 (Glut4) expressions in adipose tissue were detected by quantitative realtime polymerase chain reaction(PCR).Results Compared with high-fat fed group,HDP group had lower epididymal fat pad weight,reduced level of FBG,insulin and FFA (P ＜0.05) and improved ISI(-5.84 ± 0.24 vs-6.44 ± 0.25,P ＜ 0.05).LDP group had similar trends.In adipose tissue,the TNFα expression in LDP and HDP group was lower,Glut4 expression in HDP group was higher than that of high-fat fed group (P ＜ 0.05).Conclusion Paeoniflorin can reduce visceral adipose content,inhibit TNFα expression and increase Glut4 expression in adipose tissue,eventually lower glucose,and improve insulin resistance caused by high-fat diet.
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Objective To investigate the expressions of signal transducer and activator of transcription factor 3 (STAT3),Bcl-2,and matrix metalloproteinase 2 (MMP2) in colorectal adenomas and adenocarcinomas,and the relationship of those factors with the colorectal clinicopathological features and prognosis of intestinal adenocarcinomas,and explore their roles in invasion,metastasis,and prognosis of a colorectal cancer.Methods The samples were selected from Dongyang City People's Hospital from January 2011 to January 2012,including 50 cases of paraffin-coded colorectal mucosas with chronic inflammation,50 cases of paraffincoded colorectal adenomas,and 100 cases of paraffin-coded colorectal adenocarcinomas (35 cases with metastasis and 65 cases without distant metastasis).Envison two method was used to detect the expressions of STAT3,Bcl-2,and MMP2 in each sample.Results The expressions of STAT3,Bcl-2,and MMP2 in colorectal adenomas and adenocarcinomas were significantly higher than those in colorectal mucosas with chronic inflammation (P ＜ 0.05).The expressions of STAT3 and MMP2 in colorectal adenocarcinomas with distant metastasis were significantly higher than that those without distant metastasis (P ＜ 0.05).The expression of BCL-2 had no significant difference between colorectal adenocarcinomas with and without distant metastasis (P ＞ 0.05).Conclusions STAT3,Bcl-2 and MMP2 were associated with occurrence and development of colorectal carcinoma.STAT3 was associated with distant metastasis of colorectal carcinoma and might indicate a poor prognosis.STAT3 might be used as a candidate clinical sign for recurrence,metastasis,and poor survival prognosis of colorectal adenocarcinoma.
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Objective To detect the excision repair cross-complementing gene 1 (ERCC1) and thymidylate of the acid synthase (TS) in non-small cell lung cancer (NSCLC) and its adjacent tissue,and investigate the relationship of the expression of ERCC1 and TS with the clinical characteristics of NSCLC and prognosis for NSCLC individual therapy to provide experimental basis.Methods The protein expression levels of ERCC1 and TS in 50 cases of postoperative NSCLC cancer and adjacent tissue were detected by immunohistochemical method and the relationship among the expression of ERCC1,TS,and overall survival of patients with NSCLC Phase (OS),disease progression time (TTP),the median OS,and median TTP was analyzed.Results (1)There was an obvious difference between the expression of ERCC1,TS in cancer and paraneoplastic tissue of NSCLC,which had statistically significance (64.00％ vs 20.00％,x2 =19.87,P ＜ 0.01 ;48.00％ vs 24.00％,x2 =6.25,P ＜ 0.05) ; (2)The continued investigation in the patients who received postoperative cisplatin or carboplatin chemotherapy showed that the 0S of negative expression of ERCC1 was significantly longer than the positive one (19.10 vs 10.00 months;x2 =8.133,P =0.002),so was median TTP (15.30 vs 9.00 months; x2 =7.410,P =0.003).The median 0S of the negative expression of TS,was significantly longer than the positive one (17.80 vs 11.00 months,x2 =7.001,P =0.008),so was median TTP (11.40 vs 6.80 months; x2 =5.884,P =0.026).Conclusions ERCC1 and TS protein may become sensitive predictors of platinum chemosensitivity for NSCLC patients ; the detection of combined with ERCC1 and TS would contribute to the selection of individualized treatment programs for NSCLC.
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Objective To study the expressions of miRNAlet7 and Ras in non-small cell lung cancer ( NSCLC),and their correlations with clinicopathological features and survival time.Methods In-situ hybridization was used to detect the expression of let7,and SP immunohistochemistry to measure HMGA2 in 68 NSCLC cases ( group A) and 20 cases with normal lungs ( group B).Results The positive rate of let7 in group A was lower than that in group B (39.7％ vs 63.2％ ) ( P ＜0.05).The positive rate of Ras in group A was higher than that in group B (66.2％ vs 25.0％ ) ( P ＜0.01 ).The positive rate of let7 was not related to the age,gender,histological type,cell differentiation,and clinical stages of cancer patients(P ＞0.05).The positive rate of Ras was related to smoking,sex,and histological type of cancer( P ＜0.01 ),and was not related to cell differentiation,lymphatic metastasis,and clinical stages of cancer ( P ＞0.05).There was an obvious negative correlation between let7 and Ras( r =-0.627,P ＜0.01 ).The 2-year survival rate of let7-positive group was higher than that of the let 7-negative group ( x2 =4.84,P ＜0.05).No statistically significant difference was found between Ras-positive and-negative groups ( P ＞0.05 ).Conclusions The lower level of let7 expression,and high level of Ras expression have much to do with the carcinogenesis of NSCLC.The level of let7-positive expression is closely related to prognosis; while Ras may act in cooperativity in the occurrence and development of NSCLC.
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ObjectiveTo study the role and clinical significance of serum visfatin and retinol binding protein 4 (RBP4) in idiopathic sudden sensorineural hearing loss by measuring the change of their levels in the patients with idiopathic sudden sensorineural hearing loss.MethodsThe levels of visfatin and RBP4 were determined by ELISA method in the 102 idiopathic sudden sensorineural hearing loss patients who were observed at two different time points ( before and after treatment),and thirty-five patients with other neurologic diseases (20 with sciatica,16 with trigeminal neuralgia) and thirty healthy people were used as control.ResultsThe levels of visfatin and RBP4 in the serum of patients with idiopathic sudden sensorineural hearing loss after treatment [Visfatin (24.26 ± 2.17 ) μg/L; RBP4 (46.65± 5.26 ) mg/L]were markedly higher than the group with other neurologic diseases [Visfatin ( 20.67 ± 2.14 ) μ g/L; RBP4(34.37 ±5.73)mg/L] and the healthy control group[Visfatin(17.61 ±2.45) μg/L; RBP4 (24.82 ±5.24)mg/L] ( t =10.38,10.41,12.16,15.06,P ＜0.01),and it was significantly less than that before treatment [Visfatin(32.24 ± 2.37) μ /L; RBP4 ( 57.43 ± 6.19 ) mg/L] ( t =17.25,15.12,P ＜ 0.01 ).The levels visfatin and RBP4 in serum of severe group with idiopathic sudden sensorineural hearing loss [Visfatin ( 36.52 ± 2.46 ) μg/L; RBP4 (67.17 ± 5.92 ) mg/L] were markedly higher than those in the moderate group[Visfatin(28.92 ±2.26)μg/L; RBP4 (55.34±5.95)mg/L]( t =11.21,11.17,P ＜0.01).The levels visfatin and RBP4 in serum of moderate group were markedly higher than those in the mild group [Visfatin ( 25.31 ± 2.32 ) μg/L; RBP4 ( 47.48 ± 5.82 ) mg/L],all these differences were statistically significant( t =10.43,10.49,P ＜0.01 ).There was a positive correlation between visfatin and RBP4 in patients with idiopathic sudden sensorineural hearing loss ( r =0.68,P ＜ 0.01 ).ConclusionsThe levels of serum visfatin and RBP4 have instructive significance in idiopathic sudden sensorineural hearing loss treatingand prognosis estimating