Acetylcholinesterase inhibitors are ineffective in MuSK-antibody positive myasthenia gravis: Results of a study on 202 patients

BACKGROUND

Myasthenia gravis (MG) with MuSK antibodies (MuSK-MG) represents a distinct subtype with different responses to treatments compared to patients with AChR antibodies, especially in terms of tolerance to acetylcholinesterase inhibitors (AChEI). However, AChEI are often used as first line symptomatic treatment in MuSK-MG, despite reports that they are poorly tolerated, seldom effective or even deleterious.

METHODS

We analyzed demographic, clinical and therapeutic responses and side-effects in the large cohort of 202 MuSK-MG patients cared for at the MG Clinic of Azienda Ospedaliero-Universitaria Pisana.

RESULTS

165 patients had received AChEI at first evaluation. Only 7/165 patients (4.2%) reported an initial clinical benefit. Conversely, 76.9% of patients reported at least one side effect, most commonly neuromuscular hyperexcitability (68.4%), gastrointestinal (53.9%) and neurovegetative (35.8%) disturbances. 56 (33.9%) patients reported a concomitant worsening of muscle weakness and twelve patients (7.3%) suffered a cholinergic crisis. According to these patients, the severity of cholinergic side effects was greater at higher doses of AChEI, but side effects occurred regardless of the dose administered and ceased once the drug was discontinued.

CONCLUSIONS

This is the largest population of MuSK-MG patients reported for perceived responsiveness and tolerance to AChEI treatment. Our obervations strongly suggest avoiding this treatment in MuSK-MG.

Absorbed dose evaluation of a blood irradiator with alanine, TLD-100 and ionization chamber

Irradiation of blood bags using X-ray irradiators and dosimetry services are required to ensure uniform dose levels in the range 25-50 Gy to prevent Transfusion Associated Graft versus Host Disease (TA-GvHD). An absorbed dose characterization of a Raycell MK2 X-Irradiator was performed using three different dosimetric systems. Results showed a dosimetric accuracy of the ionization chamber together with the Alanine dosimeter. TLDs measurements exhibited a small overestimation by 4% of the absorbed dose. The Dose Uniformity Ratio (DUR), between maximum and minimum dose levels in the canister, was in good agreement with the manufacturer specifications (≤1.5).

Do changes in Lactuca sativa metabolic performance, induced by mycorrhizal symbionts and leaf UV-B irradiation, play a role towards tolerance to a polyphagous insect pest?

The increased ultraviolet radiation (UV) due to the altered stratospheric ozone leads to multiple plant physiological and biochemical adaptations, likely affecting their interaction with other organisms, such as pests and pathogens. Arbuscular mycorrhizal fungi (AMF) and UV-B treatment can be used as eco-friendly techniques to protect crops from pests by activating plant mechanisms of resistance. In this study, we investigated plant (Lactuca sativa) response to UV-B exposure and Funneliformis mosseae (IMA1) inoculation as well as the role of a major insect pest, Spodoptera littoralis. Lettuce plants exposed to UV-B were heavier and taller than non-irradiated ones. A considerable enrichment in phenolic, flavonoid, anthocyanin, and carotenoid contents and antioxidant capacity, along with redder and more homogenous leaf color, were also observed in UV-B-treated but not in AMF-inoculated plants. Biometric and biochemical data did not differ between AMF and non-AMF plants. AMF-inoculated plants showed hyphae, arbuscules, vesicles, and spores in their roots. AMF colonization levels were not affected by UV-B irradiation. No changes in S. littoralis-feeding behavior towards treated and untreated plants were observed, suggesting the ability of this generalist herbivore to overcome the plant chemical defenses boosted by UV-B exposure. The results of this multi-factorial study shed light on how polyphagous insect pests can cope with multiple plant physiological and biochemical adaptations following biotic and abiotic preconditioning.

Sex Pheromone Aerosol Emitters for Lobesia botrana Mating Disruption in Italian Vineyards

Despite the great amount of information on the European Grapevine Moth (EGVM), Lobesia botrana (Lepidoptera: Tortricidae), and the effective strategies available for its management, this moth remains the main key pest damaging grapevines in the Mediterranean and Central Europe wine-growing areas. Synthesizing and manipulating its sex pheromone components fostered the development of new dispensers to boost the effectiveness and sustainability of mating disruption (MD) programs. Recent MD research has highlighted that the effectiveness of aerosol emitters is comparable to that of passive dispensers when applied in large, uniform sites such as Spanish vineyards. However, aerosol emitters that are equally effective in geographical areas characterized by small-sized vineyards, typical of many Italian regions, have not received enough research attention. To face this challenge, herein the experimental aerosol emitter (product code: Isonet^® L MISTERX843) was tested at three different application rates (i.e., 2, 3 and 4 units/ha) in three study sites, two in Tuscany (Central Italy in 2017 and 2018) and one in Emilia-Romagna (Northern Italy in 2017), respectively, for a total of five trials. To assess the efficacy of this novel MD aerosol emitter, three different application densities were compared with an untreated control and two grower's standards. The latter were represented by passive (Isonet^® L TT) and active (Checkmate^® Puffer^® LB) release dispensers, already on the market for EGVM MD and applied at, respectively, 200-300 and 2.5-4 units/ha. MD carried out with Isonet^® L MISTERX843 led to zero catches of males in the pheromone traps. They also allowed for a significant reduction in the number of infested flower clusters and bunches, as well as in the number of nests per flowers cluster/bunch, if compared to the untreated control. As a general trend, MD effectiveness was fully comparable, or even better, if compared to the grower's standard. In conclusion, our research pointed out that the Isonet^® L MISTERX843 can allow for effective EGVM management in small-sized Italian vineyards. Lastly, our economic evaluation showed that the MD whole cost per hectare using active or passive release devices was comparable.

Leaf UV-B Irradiation and Mycorrhizal Symbionts Affect Lettuce VOC Emissions and Defence Mechanisms, but Not Aphid Feeding Preferences

Arbuscular mycorrhizal fungi (AMF) and ultraviolet-B radiation (UV-B) play important roles in plant-insect interactions by altering plant physiology and histology. We hypothesized that UV-B-induced oxidative stress was mitigated by AMF symbiosis. In this study, we conducted a multifactorial experiment to explore lettuce plant response to AMF inoculation and UV-B exposure (0.4 W m^-2; 16 h d^-1; 2 weeks), either together or individually, as well as the interaction with the polyphagous insect pest Myzus persicae (Sulzer). Lettuce plants subjected to UV-B radiation showed an increase in callose and oxidative stress indicators, as well as a decrease in stomatal density. Mycorrhizal colonization cancelled out the effect of UV-B on stomatal density, while the symbiosis was not affected by UV-B treatment. The plant volatile emission was significantly altered by UV-B treatment. Specifically, the non-terpene 1-undecene abundance (+M/+UVB: 48.0 ± 7.78%; -M/+UVB: 56.6 ± 14.90%) was increased, whereas the content of the non-terpene aldehydes decanal (+M/+UVB: 8.50 ± 3.90%; -M/+UVB: 8.0 ± 4.87%) and undecanal (+M/+UVB: 2.1 ± 0.65%; -M/+UVB: 1.20 ± 1.18%) and the sesquiterpene hydrocarbons (+M/+UVB: 18.0 ± 9.62 %; -M/+UVB: 19.2 ± 5.90%) was decreased. Mycorrhization, on the other hand, had no significant effect on the plant volatilome, regardless of UV-B treatment. Aphid population was unaffected by any of the treatments, implying a neutral plant response. Overall, this study provides new insights about the interactions among plants, UV-B, and AMF, outlining their limited impact on a polyphagous insect pest.

The Essential Oil from the Resurrection Plant Myrothamnus moschatus Is Effective against Arthropods of Agricultural and Medical Interest

This work aimed to evaluate the chemical composition, insecticidal and acaricidal potential of the essential oil (EO) obtained from the resurrection plant Myrothamnus moschatus (Baill.) Baill. (Myrothamnaceae) from Madagascar. The EO bioactivity was evaluated against selected arthropod pests and vectors of agricultural and public health relevance. The most abundant volatile compounds were trans-pinocarveol (37.7 ± 4.2%) and pinocarvone (20.8 ± 3.1%), similar to the EO of the chemotype collected from the same region. Lethal concentrations (LC₅₀) or doses (LD₅₀) from acute toxicity tests were estimated for Musca domestica (L.) adults at 22.7 µg adult^-1, for Spodoptera littoralis (Boisduval) larvae at 35.6 µg larva^-1, for Culex quinquefasciatus (Say) at 43.6 µg mL^-1, for adults of Metopolophium dirhodum (Walker) at 2.4 mL L^-1, and for adults of Tetranychus urticae (Koch) at 1.2 mL L^-1. The good insecticidal and acaricidal activities determined in this work may open a new perspective on the use of this plant as a source of botanical insecticide ingredients. The exploitation of this species could also be important for the African economy, helping local farmers cultivating this plant.

The frequency of UTIs in people who undertake intermittent catheterization: A systematic review

Background

Intermittent Catheterization (IC) is a common procedure used for the management of incomplete bladder emptying in various diseases such as spinal cord injury, multiple sclerosis and benign prostatic hypertrophy. Catheterization is associated with several complications and particularly with an increased risk of developing urinary tract infections (UTIs) responsible for high morbidity worldwide and significant costs to health systems and society.Today, this health problem is still underestimated. Therefore, the aim of this study was to summarize the available evidence on the clinical and epidemiological burden of UTIs among patients performing IC.

Methods

A systematic literature review was performed querying two online database (PubMed,Web of Science) from January 2012 to January 2022. All studies in English language and focused on the clinical-epidemiological burden of UTIs related to IC in the adult population were included.

Results

Overall, 43 studies were considered. It was described a range of UTIs from 26% to 63%, with an increased number of hospital admissions and length of stay. UTIs were more common in patients with spinal cord injuries (about 40%) and with multiple sclerosis (24-34%).The main risk factors associated with UTIs were catheter reuse, type of catheter and catheterization procedure adopted.

Conclusions

Data on IC-associated UTIs are still limited. Estimating the UTIs load in patients with IC could support healthcare professionals to identify the most appropriate type of catheter to reduce the risk of this important complication. Proper management of catheterization could improve patients’ quality of life and also reduce the impact of diseases associated with this procedure on health systems and society.

Key messages

Peristomal skin complications in ileostomy and colostomy patients: a systematic literature review

Background

Peristomal skin complications (PSCs) are one of the main post-operative complications of ostomy surgery. They have a considerable impact on patients’ quality of life and represent a challenge for healthcare professionals involved in their management. The majority of PSCs is preventable and costly. Knowing their burden could guide decision makers on the ostomy patients’ management who are predominantly cancer and chronic bowel disease patients. Thus, the aim of this study was to summarize existing literature regarding the clinical-epidemiological burden of PSCs in ostomy patients.

Methods

A systematic literature review was performed querying three database (PubMed, Scopus, Web of Science) from January 2012 to February 2022. It included studies in English language and focused on the clinical and epidemiological burden of PSCs in the adult patients with ileostomy and colostomy.

Results

Overall, 35 studies were considered. Epidemiological data on PSCs were not systematically collected in the available literature. The principal underlying disease requiring the ostomy surgery were rectal, colon and gynaecological cancers, inflammatory bowel diseases, diverticulitis, occlusion and intestinal perforation. It was described a range of PSCs from 11% to 45%. The PSCs were most commonly erythema, papules, erosion, ulceration and vesciculation. Skin complications increased the average number of hospitalization days and of hospital readmission within 120-day following surgery.

Conclusions

The data on PSCs are still limited. Estimating the PSCs burden could support healthcare professionals and decision makers called upon to identify the most appropriate responses to patients’ health needs. The management of these complications plays a vital role to improve patient’s quality of life and a multidisciplinary approach with the active involvement of stomatherapist, surgeon and dermatologist is critical. Furthermore, a better patient education and empowerment is needed.

Key messages

• Developing a multidisciplinary approach to managing PSCs is essential in order to provide the best treatment possible and the best outcomes for patients.

• Further studies should be conducted in order to better define the clinical-epidemiological burden of ileo- and colostomies and to support better health planning.

Insecticidal Activity of Four Essential Oils Extracted from Chilean Patagonian Plants as Potential Organic Pesticides

Patagonia is a geographical area characterized by a wide plant biodiversity. Several native plant species are traditionally used in medicine by the local population and demonstrated to be sources of biologically active compounds. Due to the massive need for green and sustainable pesticides, this study was conducted to evaluate the insecticidal activity of essential oils (EOs) from understudied plants growing in this propitious area. Ciprés (Pilgerodendron uviferum), tepa (Laureliopsis philippiana), canelo (Drimys winteri), and paramela (Adesmia boronioides) EOs were extracted through steam distillation, and their compositions were analyzed through GC−MS analysis. EO contact toxicity against Musca domestica L., Spodoptera littoralis (Boisd.), and Culex quinquefasciatus Say was then evaluated. As a general trend, EOs performed better on housefly males over females. Ciprés EO showed the highest insecticidal efficacy. The LD50(90) values were 68.6 (183.7) and 11.3 (75.1) µg adult−1 on housefly females and males, respectively. All EOs were effective against S. littoralis larvae; LD50 values were 33.2−66.7 µg larva−1, and tepa EO was the most effective in terms of LD90 (i.e., <100 µg larva−1). Canelo, tepa, and paramela EOs were highly effective on C. quinquefasciatus larvae, with LC50 values < 100 µL L−1. Again, tepa EO achieved LD90 < 100 µL L−1. This EO was characterized by safrole (43.1%), linalool (27.9%), and methyl eugenol (6.9%) as major constituents. Overall, Patagonian native plant EOs can represent a valid resource for local stakeholders, to develop effective insecticides for pest and vector management, pending a proper focus on their formulation and nontarget effects.

Echoentomography for Assessing Braconid Parasitization on Soft-Bodied Tephritid Hosts

Entomological approaches currently available for assessing host parasitization require dissection, polymerase chain reaction (PCR), or waiting for adult emergence. The first two methods are relatively fast but destructive, whereas the third one allows the emergence of the parasitoid but it is time consuming. In this framework, new diagnostic imaging tools may contribute to solve the lack of an accurate, rapid, and non-invasive approach to evaluate the parasitization of soft-bodied insects by their endoparasitoids. In this study, ultra-high frequency ultrasound (UHFUS) technology, which is currently used in medical and preclinical fields, was adopted to assess the parasitization of the invasive polyphagous Mediterranean fruit fly, Ceratitis capitata (Diptera: Tephritidae), testing 2nd and 3rd instar larvae. Parasitization assays were carried out with the solitary koinobiont endophagous parasitoid Psyttalia concolor (Hymenoptera: Braconidae: Opiinae). The efficacy of UHFUS-based echoentomography was compared with the classical method of dissecting the larval host under a stereomicroscope. Our results showed that the UHFUS diagnostic capability was statistically comparable with that of dissection, both on C. capitata 2nd and 3rd larvae. Overall, UHFUS-based echoentomography may be further considered as a fast, non-invasive, and effective approach to evaluate the parasitoid's ability to successfully oviposit in soft-bodied hosts.

Mating Disruption for Managing the Honeydew Moth, Cryptoblabes gnidiella (Millière), in Mediterranean Vineyards

Simple Summary

Cryptoblabes gnidiella has recently become one of the most feared pests in the Mediterranean grape-growing areas. Its expanding impact requires the development of effective strategies for its management. Since insecticide strategy has shown several weaknesses, we developed a pheromone-based mating disruption (MD) approach as a possible sustainable control technique for this pest. Between 2016 and 2019, field trials were carried out in two study sites in central and southern Italy, using experimental pheromone dispensers. The number of adult captures in pheromone-baited traps and the percentage of infestation recorded on ripening grapes were compared among plots treated with MD dispensers, insecticide-treated (no MD) plots, and untreated plots. Results highlighted that the application of MD may contribute to lowering the damage significantly. However, further studies aimed at clarifying the still little-known aspects of the biology and population dynamics of the honeydew moth are needed.

Abstract

The demand for a reduced use of pesticides in agriculture requires the development of specific strategies for managing arthropod pests. Among eco-friendly pest control tools, pheromone-based mating disruption (MD) is promising for controlling several key insect pests of economic importance, including many lepidopteran species. In our study, we evaluated an MD approach for managing the honeydew moth (HM), Cryptoblabes gnidiella, an emerging threat for the grapevine in the Mediterranean basin. The trials were carried out in two study sites, located in Tuscany (central Italy, years 2017–2019) and Apulia (southern Italy, years 2016 and 2018–2019), and by applying MD dispensers only in April, in April and July, and only in July. To evaluate the effects of MD, infested bunches (%), damaged area (%) per bunch, and number of living larvae per bunch were compared among plots covered with MD dispensers, insecticide-treated plots (Apulia only), and untreated control plots. Male flights were monitored using pheromone-baited sticky traps. Except for the sampling carried out in Tuscany in 2018, where HM infestation level was very low, a significant difference was recorded between MD and control plots, both in terms of HM damage caused to ripening grapes and/or number of living larvae per bunch. Overall, our study highlighted that MD, irrespective of the application timing, significantly reduced HM damage; the levels of control achieved here were similar to those obtained with the application of insecticides (no MD). However, MD used as stand-alone strategy was not able to provide complete pest control, which may instead be pursued by growers with an IPM approach.

Wing-fanning frequency as a releaser boosting male mating success-High-speed video analysis of courtship behavior in Campoplex capitator, a parasitoid of Lobesia botrana

Campoplex capitator is an ichneumonid parasitoid with a narrow host range, comprising grapevine moth pests. Despite being considered one of the possible candidates for biocontrol of Lobesia botrana, knowledge about its biology is limited and mass-rearing for commercial purposes is still lacking. This research provides a quantitative analysis of the C. capitator courtship and mating behavior. C. capitator mating sequence was analyzed by high-speed video recordings. Main behavioral parameters, with special reference to male wing fanning and antennal tapping, were quantified and linked with mating success. Furthermore, we analyzed the occurrence of population-level behavioral asymmetries during C. capitator sexual interactions and their impact on male success. Results showed that male wing fanning was crucial to successfully approach the female. Males achieving higher mating success performed wing-fanning at higher frequencies over unsuccessful ones. After wing fanning, most of males palpated the female's body with their antennae, before attempting copulation. The overall mating success was >70%, with a rather long copula duration (254.76 ± 14.21 s). Male wing-fanning was lateralized on the left at population level, while antennal tapping displays were right-biased. Side-biased male displays do not differ in terms of frequency and duration of their main features. This research adds basic knowledge to the C. capitator behavioral ecology. Since rearing protocols for C. capitator are being developed, male wing fanning frequency may represent a useful benchmark for monitoring mate quality over time, tackling mating success reductions due to prolonged mass-rearing.

Developing a Highly Stable Carlina acaulis Essential Oil Nanoemulsion for Managing Lobesia botrana

The growing interest in the development of green pest management strategies is leading to the exploitation of essential oils (EOs) as promising botanical pesticides. In this respect, nanotechnology could efficiently support the use of EOs through their encapsulation into stable nanoformulations, such as nanoemulsions (NEs), to improve their stability and efficacy. This technology assures the improvement of the chemical stability, hydrophilicity, and environmental persistence of EOs, giving an added value for the fabrication of natural insecticides effective against a wide spectrum of insect vectors and pests of public and agronomical importance. Carlina acaulis (Asteraceae) root EO has been recently proposed as a promising ingredient of a new generation of botanical insecticides. In the present study, a highly stable C. acaulis-based NE was developed. Interestingly, such a nanosystem was able to encapsulate 6% (w/w) of C. acaulis EO, showing a mean diameter of around 140 nm and a SOR (surfactant-to-oil ratio) of 0.6. Its stability was evaluated in a storage period of six months and corroborated by an accelerated stability study. Therefore, the C. acaulis EO and C. acaulis-based NE were evaluated for their toxicity against 1st instar larvae of the European grapevine moth (EGVM), Lobesia botrana (Denis & Schiffermüller, 1775) (Lepidoptera: Tortricidae), a major vineyard pest. The chemical composition of C. acaulis EO was investigated by gas chromatography-mass spectrometry (GC-MS) revealing carlina oxide, a polyacetylene, as the main constituent. In toxicity assays, both the C. acaulis EO and the C. acaulis-based NE were highly toxic to L. botrana larvae, with LC₅₀ values of 7.299 and 9.044 µL/mL for C. acaulis EO and NE, respectively. The C. acaulis-based NE represents a promising option to develop highly stable botanical insecticides for pest management. To date, this study represents the first evidence about the insecticidal toxicity of EOs and EO-based NEs against this major grapevine pest.

Multiple Mating in the Citrophilous Mealybug Pseudococcus calceolariae: Implications for Mating Disruption

The citrophilous mealybug Pseudococcus calceolariae (Maskell) (Hemiptera, Pseudococcidae) is a primary pest of various crops, including grapevines. The use of insecticides against this species is difficult in most cases because its life cycle includes an extended duration of eggs, juveniles, and adults under the bark and on the roots. Pheromone-based control strategies can present new eco-friendly opportunities to manage this species, as in the case of Planococcus ficus (Signoret) and Planococcus citri (Risso). With this aim it is critical to understand behavioral aspects that may influence pheromone-based control strategies. Herein, the capability of males to fertilize multiple females was investigated, trying to understand whether this behavior could negatively impact the efficacy of mass trapping, mating disruption, or the lure and kill technique. Results showed that a P. calceolariae male can successfully mate and fertilize up to 13 females. The copulation time in subsequent mating events and the time between copulations did not change over time but the number of matings per day significantly decreased. In a further experiment, we investigated the mate location strategy of P. calceolariae males, testing the attractiveness of different loadings of sex pheromone on males in a flight tunnel. Males constantly exposed to 16 rubber septa loaded with the sex pheromone showed a significant decrease in female detection at 1 and 30 μg loadings (0.18 and 0.74 visits per female for each visit per septum, respectively), whereas in the control about 9.2-fold more of the released males successfully detected the female in the center of the array of 16 septa without pheromone. Male location of females in the control (45%) was significantly higher than in the arrays with surrounding pheromone (5% and 20% at 1 and 30 μg loadings, respectively). Mating only occurred in the control arrays (45%). This study represents a useful first step to developing pheromone-based strategies for the control of citrophilous mealybugs.

Managing the vine mealybug, Planococcus ficus, through pheromone-mediated mating disruption

The vine mealybug (VMB), Planococcus ficus (Hemiptera: Pseudococcidae), is a key insect pest of vineyards. While pheromone-based mating disruption (MD) has been successfully tested against a wide range of insect pests, knowledge about its efficacy against key mealybug species, such as P. ficus, is scarce. In this study, a novel MD product, Isonet® PF, was evaluated by testing 300, 400, and 500 dispensers/ha at four study sites located in Northern (Veneto) and Southern (Sicily) Italy. Experiments were carried out over 2 years by monitoring the mealybug populations in wine grape and table grape vineyards managed with and without the application of MD. Pheromone dispensers were periodically collected during the grapevine-growing season, extracted, and analyzed by GC-MS, to determine their pheromone content and the release in mg/ha/day. The results showed that use of the MD dispenser Isonet® PF reduced the percentage of VMB-infested bunches and the number of VMB specimens per bunch compared with the untreated controls. This was recorded over 2 years at all experimental sites. Differences in the incidence of infested bunches among the three tested rates of Isonet® PF were not detected. Overall, the results presented here contribute to optimizing the sex pheromone dosage used in MD control programs against VMB allowing a reduction of broad-spectrum insecticides currently employed to manage this important pest.

Acquired neuromyotonia in thymoma-associated myasthenia gravis: a clinical and serological study

Background and purpose

Acquired neuromyotonia can occur in patients with thymoma, alone or in association with myasthenia gravis (MG), but the clinical prognostic significance of such comorbidity is largely unknown. The clinico‐pathological features were investigated along with the occurrence of neuromyotonia as predictors of tumour recurrence in patients with thymoma‐associated myasthenia.

Methods

A total number of 268 patients with thymomatous MG were studied retrospectively. Patients with symptoms of spontaneous muscle overactivity were selected for autoantibody testing using immunohistology for neuronal cell‐surface proteins and cell‐based assays for contactin‐associated protein 2 (CASPR2), leucine‐rich glioma inactivated 1 (LGI1), glycine receptor and Netrin‐1 receptor antibodies. Neuromyotonia was diagnosed according to the presence of typical electromyography abnormalities and/or autoantibodies against LGI1/CASPR2.

Results

Overall, 33/268 (12%) MG patients had a thymoma recurrence. Five/268 (2%) had neuromyotonia, four with typical autoantibodies, including LGI1 (n = 1), CASPR2 (n = 1) or both (n = 2). Three patients had Netrin‐1 receptor antibodies, two with neuromyotonia and concomitant CASPR2+LGI1 antibodies and one with spontaneous muscle overactivity without electromyography evidence of neuromyotonia. Thymoma recurrence was more frequent in those with (4/5, 80%) than in those without (28/263, 10%, P < 0.001) neuromyotonia. Neuromyotonia preceded the recurrence in 4/5 patients. In univariate analysis, predictors of thymoma recurrence were age at thymectomy [odds ratio (OR) 0.95, 95% confidence interval (CI) 0.93–0.97], Masaoka stage ≥IIb (OR 10.73, 95% CI 2.38–48.36) and neuromyotonia (OR 41.78, 95% CI 4.71–370.58).

Conclusions

De novo occurrence of neuromyotonia in MG patients with previous thymomas is a rare event and may herald tumour recurrence. Neuronal autoantibodies can be helpful to assess the diagnosis. These observations provide pragmatic risk stratification for tumour vigilance in patients with thymomatous MG.

Updated list of the insect parasitoids (Insecta, Hymenoptera) associated with Lobesia botrana (Denis & Schiffermüller, 1775) (Lepidoptera, Tortricidae) in Italy. 2. Hymenoptera, Ichneumonidae, Anomaloninae and Campopleginae

In this second review of the parasitoids recorded on Lobesia botrana (EGVM) in Italy, an updated list and summary of the information available on 14 taxa of Ichneumonidae belonging to the subfamilies Anomaloninae and Campopleginae are provided. For each taxon, geographic distributions, host ranges, ecological role in viticulture and/or in other crops, and taxonomy are provided and discussed. For the most interesting species, tables summarizing the parasitization rates recorded in the field on EGVM or other lepidopteran pests are given. Identification mistakes and wrong synonymies that have generated great confusion and often made geographic distributions and host ranges unreliable are highlighted. A list of four Anomaloninae and 27 Campopleginae recorded on EGVM in Europe is also provided. Among the species examined, Campoplex capitator Aubert is the only potential candidate for biological control of EGVM.

Eco-friendly pheromone dispensers-a green route to manage the European grapevine moth?

The development of environmentally sustainable control strategies to fight insect pests is a key challenge nowadays. Pheromone-mediated mating disruption (MD) is based on the release of synthetic sex attractants into a crop, interfering with mate finding of a given pest species. However, a limited number of research items have been published on the optimization of MD strategies against the European grapevine moth, Lobesia botrana, as well as on the use of biodegradable dispensers to reduce waste production in vineyards, despite the high economic importance of this pest. Therefore, the present study evaluated the efficacy of the MD products Isonet® L TT and the biodegradable Isonet® L TT BIO, applied at various densities, in reducing L. botrana damage on grapevine in comparison to an untreated control and the reference MD product Isonet® L. Experiments were conducted in three different areas of grapevine cultivation, located in Central and Northern Italy, over three different years. Our MD approach allowed a reliable control of the three generations of L. botrana during the whole grape growing season, leading to a significant reduction in the infested flower clusters and bunches, as well as in the number of nests per flower cluster and bunch, if compared to the untreated control. The performances of Isonet® L TT BIO, Isonet® LTT, and Isonet® L did not differ in terms of infested flower clusters/bunches, as well as nests per flower cluster/bunch. This was confirmed in all experimental sites over 3 years of field experiments. Overall, the present research provides useful information for the optimization of MD programs against L. botrana, highlighting the interesting potential of biodegradable pheromone dispensers that can be easily applied at low densities in vineyards, reducing the use of chemical pesticides to control moth pests.

What is the optimal management of an intra-operative air leak in a colorectal anastomosis?

AIM

An airtight anastomosis on intra-operative leak testing has been previously demonstrated to be associated with a lower risk of clinically significant postoperative anastomotic leak following left-sided colorectal anastomosis. However, to date, there is no consistently agreed upon method for management of an intra-operative anastomotic leak. Therefore, we powered a noninferiority study to determine whether suture repair alone was an appropriate strategy for the management of an intra-operative air leak.

METHOD

This is a retrospective cohort analysis of prospectively collected data from a tertiary care referral centre. We included all consecutive patients with left-sided colorectal or ileorectal anastomoses and evidence of air leak during intra-operative leak testing. Patients were excluded if proximal diversion was planned preoperatively, a pre-existing proximal diversion was present at the time of surgery or an anastomosis was ultimately unable to be completed. The primary outcome measure was clinically significant anastomotic leak, as defined by the Surgical Infection Study Group at 30 days.

RESULTS

From a sample of 2360 patients, 119 had an intra-operative air leak during leak testing. Sixty-eight patients underwent suture repair alone and 51 underwent proximal diversion or anastomotic reconstruction. The clinically significant leak rate was 9% (6/68; 95% CI: 2-15%) in the suture repair alone arm and 0% (0/51) in the diversion or reconstruction arm.

CONCLUSION

Suture repair alone does not meet the criteria for noninferiority for the management of intra-operative air leak during left-sided colorectal anastomosis. Further repair of intra-operative air leak by suture repair alone should be reconsidered given these findings.

Characterization of Self-Assembled Monolayers on a Ruthenium Surface

We have modified and stabilized the ruthenium surface by depositing a self-assembled monolayer (SAM) of 1-hexadecanethiol on a polycrystalline ruthenium thin film. The growth mechanism, dynamics, and stability of these monolayers were studied. SAMs, deposited under ambient conditions, on piranha-cleaned and piranha + H₂SO₄ cleaned substrates were compared to monolayers formed on H-radical-cleaned Ru surfaces. We found that alkanethiols on H-radical-cleaned Ru formed densely packed monolayers that remained stable when kept in a nitrogen atmosphere. X-ray photoelectron spectroscopy (XPS) shows a distinct sulfur peak (BE = 162.3 eV), corresponding to metal-sulfur bonding. When exposed to ambient conditions, the SAM decayed over a period of hours.

High prevalence of diabetes-specific autoimmunity in first-degree relatives of Sardinian patients with type 1 diabetes

BACKGROUND

The incidence of type 1 diabetes mellitus (T1DM) in Sardinia is among the highest in the world (44.8 cases/100,000 person-years). Recommendations of the Immunology of Diabetes Society advise evaluating autoantibody positivity in first-degree relatives (FDRs) of patients with T1DM, for their higher risk to develop the disease. The aim of this study was to determine the prevalence of beta-cell autoimmunity in FDRs of T1DM patients in Sardinia.

METHODS

A total of 188 Sardinian families were recruited in collaboration between diabetes and pediatric units of university and district hospitals in Sardinia. The recruitment involved 188 patients with diagnosed T1DM and all their available FDRs (n = 447). Autoantibodies (Aabs) against GAD, IA2, insulin, and ZnT8 were measured in all subjects. Human leukocyte antigen (HLA) risk genotypes (HLA-DR and DQ loci) were analyzed in 43 Aabs-positive FDR.

RESULTS

The prevalence of Aabs (any type of autoantibody, single or multiple) in FDR was 11.9% (53/447). Of those with autoantibodies, 62.3% (33/53) were positive to only 1 autoantibody, 22.6% (12/53) had 2 autoantibodies, 7.55% (4/53) had 3 autoantibodies, and 7.55% (4/53) had all 4 autoantibodies. Typing of HLA-DR and DQ loci showed that 89% of FDR carried moderate- to high-risk genotypes, with only 5 FDR with low-risk genotypes.

CONCLUSIONS

The prevalence of T1DM autoantibodies in FDRs of T1DM patients was very high (11.9%) in the Sardinian population, higher than in other populations from the United States and Europe, and similar to that observed in Finland. Autoantibody positivity strongly associated with HLA risk. This study provides evidence of the high risk of T1DM in FDR of T1DM patients in Sardinia and warrants longitudinal follow-up to estimate the risk of progression to T1DM in high-risk populations.

Uracil-DNA glycosylases-structural and functional perspectives on an essential family of DNA repair enzymes

Uracil-DNA glycosylases (UDGs) are evolutionarily conserved DNA repair enzymes that initiate the base excision repair pathway and remove uracil from DNA. The UDG superfamily is classified into six families based on their substrate specificity. This review focuses on the family I enzymes since these are the most extensively studied members of the superfamily. The structural basis for substrate specificity and base recognition as well as for DNA binding, nucleotide flipping and catalytic mechanism is discussed in detail. Other topics include the mechanism of lesion search and molecular mimicry through interaction with uracil-DNA glycosylase inhibitors. The latest studies and findings detailing structure and function in the UDG superfamily are presented.

Structure of the uracil complex of Vaccinia virus uracil DNA glycosylase

Poxvirus uracil DNA glycosylases are the most diverse members of the family I uracil DNA glycosylases (UNGs). The crystal structure of the uracil complex of Vaccinia virus uracil DNA glycosylase (D4) was determined at 2.03 Å resolution. One uracil molecule was located in the active-site pocket in each of the 12 noncrystallographic symmetry-related D4 subunits. Although the UNGs of the poxviruses (including D4) feature significant differences in the characteristic motifs designated for uracil recognition and in the base-excision mechanism, the architecture of the active-site pocket in D4 is very similar to that in UNGs of other organisms. Overall, the interactions of the bound uracil with the active-site residues are also similar to the interactions previously observed in the structures of human and Escherichia coli UNG.

How often do patients return to the operating room after colorectal resections?

AIM

We sought to identify the rate of re-operation after an index colorectal surgical procedure and potential contributing risk factors.

METHOD

This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned or did not return to the operating room after any colorectal resection from January 2005 to December 2008.

RESULTS

From a total cohort of 635, 265 patients included in the National Surgical Quality Improvement Program over the 4-year study period, we identified 54, 237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4 ± 0.1% of non colorectal resection patients and 7.6 ± 0.2% of colorectal resection patients (P < 0.001). The multivariate model identified patients with postoperative diagnostic codes for abdominal cavity hernia or colostomy complication as having the highest odds of return to the operating room within 30 days. Patients returning to the operating room had longer length of stay and higher overall mortality compared with those patients who did not return to the operating room.

CONCLUSION

Return to the operating room is a relatively common occurrence after colorectal resections, with an associated high rate of mortality. Given the association between return to the operating room and adverse patient outcomes, emphasis should be placed on determining strategies to reduce the need for return to the operating room.

Do admissions and discharges to long-term care facilities influence hospital burden of Clostridium difficile infection?

BACKGROUND

Substantial geographical clustering of Clostridium difficile infection (CDI) outbreaks in hospitals in the USA have previously been demonstrated.

AIM

To test the hypothesis that hospital burden of CDI is associated with admission from and discharge to long-term care facilities (LTCFs).

METHODS

Hospital discharge data from 19 states in the USA were used to identify all patients discharged with a diagnosis of CDI from 1 January 2002 to 31 December 2004. For every hospital, the proportion of discharges with a diagnosis of CDI was calculated, and those above the 90th percentile were classified as 'high CDI' hospitals. We tested the association between this measure of hospital burden of CDI and the rates of admission from and discharges to LTCFs. We adjusted for other hospital level characteristics, case-complexity and local population characteristics.

FINDINGS

We identified 38,372,951 discharges during the three-year study period. Of all discharges, 274,311 (0.71%) had a primary or secondary diagnosis of CDI. Hospitals had a mean CDI burden of 7.8 cases per 1000 discharges. High CDI hospitals (N = 610; 10.0%) had a mean CDI burden of 34.8 cases per 1000 discharges. Compared to other hospitals, high CDI hospitals were more likely to have a high proportion of admissions from or discharges to LTCFs. This association persisted after adjustments for other hospital characteristics, case-complexity, and area population characteristics.

CONCLUSION

A high rate of admission from or discharge to LTCFs is associated with an increased hospital burden of CDI.

In vitro activity of tigecycline against multidrug-resistant Acinetobacter baumannii clinical isolates

This survey was conducted to evaluate the in vitro activity of tigecycline against 50 isolates of multidrug-resistant (MDR) Acinetobacter baumannii. Isolates of A. baumannii were resistant to ciprofloxacin, chloramphenicol, imipenem, levofloxacin, piperacillin and piperacillin-tazobactam, but were always susceptible to colistin. MICs of tigecycline were determined by E-test in Mueller-Hinton agar. The results of the study showed that 50% of the A. baumannii strains were susceptible to tigecycline.

[In vitro activity of voriconazole and other antifungal agents against clinical isolates of 138 Candida spp]

Voriconazole is used for treating invasive Aspergillosis, Fusarium and Scedosporium infections as well as resistant candidiasis. It is referred to as a second generation triazole. The purpose of this study was to evaluate the concordance of the results of antifungal voriconazole susceptibility tests for yeast isolates, comparing the Sensititre YeastOne method, Atb Fungus 3 and Etest. In all, 138 yeast isolates (42 C. tropicalis, 36 C. glabrata, 14 C. albicans, 8 C. famata, 6 C. parapsilosis, 4 C. dubliniensis, 3 C. krusei, 3 C. lusitaniae, 2 C. zeylanoides, 20 Candida spp.) were tested for susceptibility to amphotericin B, flucytosine, fluconazole , itraconazole and voriconazole with Atb Fungus 3 method. The concordance between the Sensititre YeastOne method, Atm Fungus 3 and Etest for voriconazole was high (90%).

[Some behavioral characteristics of physicians desired by ambulatory patients. A pilot survey]

AIMS

We must pay attention to character formation of Medical Doctors because it could build a good or bad relationship with colleagues and patients: it is not a merely "humanistic" goal but a necessary component of professional excellence. The first endpoint of this study is to identify how to improve the quality of the outpatient visit.

MATERIALS AND METHODS

We tested a user-friendly questionnaire, distributed to 100 patients.

RESULTS AND CONCLUSIONS

The most important behavioral characteristics desired by patients from physicians are: 1. to have the physician's attention without feeling hurried (such as without the physician answering a phone call during the office visit); 2. to have continuity of care even in the ambulatory setting; 3. to find a relationship of empathy, participation and sharing; 4. to have a peaceful relationship of collaboration with the nurses and other health care personnel; 5. to find the physician appropriately groomed and dressed; 6. to receive the full diagnosis with clarity and at the most appropriate moment of communication.

Predictors of Clostridium difficile colitis infections in hospitals

Hospital-level predictors of high rates of 'Clostridium difficile-associated disease' (CDAD) were evaluated in over 2300 hospitals across California, Arizona, and Minnesota. American Hospital Association data were used to determine hospital characteristics associated with high rates of CDAD. Significant correlations were found between hospital rates of CDAD, common infections and other identified pathogens. Hospitals in urban areas had higher average rates of CDAD; yet, irrespective of geographic location, hospital rates of CDAD were associated with other infections. In addition, hospitals with 'high CDAD' rates had slower turnover of beds and were more likely to offer transplant services. These results reveal large differences in rates of CDAD across regions. Hospitals with high rates of CDAD have high rates of other common infections, suggesting a need for broad infection control policies.

Blastomyces dermatitidis of the perianal skin: report of a case

Isolated fungal infections of the perianal skin are rare and their diagnosis is frequently overlooked. We report a case of a 78-year-old male patient who presented with a friable, violaceous, papulopustular lesion, with heaped-up edges along the anal verge. Biopsy revealed unicellular yeast consistent with blastomycosis. The patient was treated with itraconazole with resolution of this lesion. An extensive MEDLINE literature review from 1958 to the present indicates that this is an uncommon manifestation of cutaneous blastomycosis. A summary of the medical literature is presented with a review of the characteristics, diagnosis, and management of blastomycosis.

Causes of portal venous thrombosis in cirrhotic patients: the role of genetic and acquired factors

OBJECTIVE AND METHODS

We compared frequencies of three common prothrombotic mutations (factor V Leiden, the G20210A mutation of the prothrombin gene, and homozygosity for C677T methylenetetrahydrofolate reductase) in 219 cirrhotic patients, 43 with and 176 without portal vein thrombosis (PVT). The following variables were related to PVT: prothrombin levels, platelet count, Child-Pugh classification, previous abdominal surgery, number of decompensation events, size of varices, red markers on varices, and sclerotherapy. All patients were followed up for a mean period of 18 months (range 10-30).

RESULTS

Prothrombotic mutations were detected in 64 of the 219 cirrhotic patients (29.2%), at equal frequency in patients with or without PVT. At univariate analysis, PVT was associated with Child-Pugh classes B and C, signs of liver decompensation, large varices with red markings, sclerotherapy, and abdominal surgery. At multivariate analysis, PVT was associated with sclerotherapy [odds ratio (OR) 4.9, 95% confidence interval (CI) 2.2-11] and previous surgery (OR 2.8, 95% CI 1.2-6.3). The combination of the two acquired factors increased the risk of PVT, whereas the combination of local with genetic defects did not. Only a single patient with genetic thrombophilia and without PVT at inclusion developed the complication during follow-up, concomitantly with the development of hepatocellular carcinoma.

CONCLUSION

In cirrhotic patients prothrombotic mutations by themselves are not causative of PVT. Sclerotherapy and previous abdominal surgery favour the development of two-thirds of cases of PVT; in the remaining cases the pathogenesis remains elusive.

13C-breath tests in hepatology (cytosolic liver function)

13C-phenylalanine (PheBT) and 13C-galactose breath tests (GBT) explore non invasively the hepatic functional mass by measuring two enzymatic activities localized into the cytosol of liver cells: the phenylalanine hydroxylase (which converts phenylalanine into tyrosine) and the galactose kinase (which catalyzes the ATP-dependent phosphorylation of galactose to galactose 1-phosphate). Both BTs are safe and accurate in predicting the severity of liver cirrhosis showing a good correlation with the Child-Pugh score. PheBT is also used in predicting postoperative complications and monitoring liver regeneration in patients undergoing partial hepatectomy. GBT has been also used to assess liver fibrosis in patients with chronic hepatitis C. PheBT and GBT could be used in the diagnosis of two inborn errors of metabolism, phenylketonuria and galactosemia, respectively. Both BTs are not affected by enzymatic induction due to drugs which may interfere with the results of the classic "microsomial" BTs (such as the aminopyrine or caffeine BTs).

Independent Predictors of Morbidity and Mortality in Blunt Colon Trauma

We sought to determine the impact of (1) grade of the colon injury, (2) the formation of an ostomy, and (3) associated injuries on outcomes such as morbidity and mortality after blunt colon injuries. We retrospectively reviewed 16,814 cases of blunt abdominal trauma. Patients with colonic injuries were selected and charts reviewed for demographic, clinical, and outcomes data. Injuries were grouped by the Colon Injury Scale (grades I–V). Independent risk factors of morbidity included spine and lung injuries, as well as increased age. A higher grade of colon injury trended toward a significant association with intra-abdominal complications. Independent risk factors of mortality included liver, heart, and lung injuries, as well as intracerebral blood and female gender. The grade of colon injury, the formation of an ostomy, and management of the colon trauma did not independently predict increased intra-abdominal complications, morbidity, or mortality. These results indicate that patients afflicted with blunt colon trauma experience a high rate of morbidity and mortality from associated injuries and or increased age. Treatment regimens directed at these factors will be most helpful in reducing the high morbidity and mortality after blunt colon trauma. Factors such as ostomy formation and management strategy are not associated with increased morbidity or mortality after blunt colon trauma.

Independent predictors of morbidity and mortality in blunt colon trauma

We sought to determine the impact of (1) grade of the colon injury, (2) the formation of an ostomy, and (3) associated injuries on outcomes such as morbidity and mortality after blunt colon injuries. We retrospectively reviewed 16,814 cases of blunt abdominal trauma. Patients with colonic injuries were selected and charts reviewed for demographic, clinical, and outcomes data. Injuries were grouped by the Colon Injury Scale (grades I-V). Independent risk factors of morbidity included spine and lung injuries, as well as increased age. A higher grade of colon injury trended toward a significant association with intra-abdominal complications. Independent risk factors of mortality included liver, heart, and lung injuries, as well as intracerebral blood and female gender. The grade of colon injury, the formation of an ostomy, and management of the colon trauma did not independently predict increased intra-abdominal complications, morbidity, or mortality. These results indicate that patients afflicted with blunt colon trauma experience a high rate of morbidity and mortality from associated injuries and or increased age. Treatment regimens directed at these factors will be most helpful in reducing the high morbidity and mortality after blunt colon trauma. Factors such as ostomy formation and management strategy are not associated with increased morbidity or mortality after blunt colon trauma.

Appropriateness of urea breath test: a prospective observational study based on Maastricht 2000 guidelines

BACKGROUND

The urea breath test is routinely used for diagnosing or confirming the eradication of Helicobacter pylori.

AIM

To evaluate the appropriateness of urea breath test referrals.

METHODS

The age, sex, symptoms, endoscopic findings, use of non-steroidal anti-inflammatory drugs, family history of gastric cancer or H. pylori infection and concomitant diseases of patients referred for urea breath testing in a 1-year period were recorded. The appropriateness of urea breath test referrals was judged according to Maastricht guidelines.

RESULTS

One thousand, three hundred and twenty subjects (47 +/- 16 years) were referred in 2001: 578 (43.8%) for the diagnosis and 742 (56.2%) for confirmation of the eradication of H. pylori. The urea breath test was considered to be appropriate in 836 (63.3%) patients, inappropriate in 192 (14.5%) and appropriate but avoidable in 292 (22.1%). The appropriateness ratios of urea breath test referrals were 4.6 and 9.0 (P < 0.0001) for general practitioners and gastroenterologists, respectively. Of the patients (n=230) with un investigated dyspepsia, who underwent urea breath testing according to a 'test and treat' strategy, 98 (42.6%) presented at least one risk factor for organic disease.

CONCLUSIONS

In Italy, nearly 36% of urea breath test referrals are inappropriate or could be avoided if all dyspeptic patients with risk factors were referred for endoscopy or all dyspeptic patients undergoing endoscopy were tested for H. pylori infection with biopsy methods. Both general practitioners and, to a lesser extent, gastroenterologists require educational programmes to deal effectively with H. pylori.

Activator protein 1 activation following hypoosmotic stress in HepG2 cells is actin cytoskeleton dependent

BACKGROUND

Following hypoosmotic stress-induced cell volume change, the actin cytoskeleton reorganizes itself. The role of this reorganization in the activation of the phosphatidylinositol 3-OH-kinase/protein kinase B/activator protein 1 (PI-3-K/PKB/AP-1) proliferative signaling cascade is unknown. Focal adhesion kinase (FAK) participates in the cytoskeleton-based activation of PI-3-K. We hypothesized that hypoosmotic stress-induced activation of PKB and AP-1 in HepG2 cells is dependent on an intact actin cytoskeleton and subsequent FAK phosphorylation.

METHODS

HepG2 cells were incubated for 1 h with or without 20 microM cytochalasin D, an actin disrupter, and were then exposed for up to 30 min to hypoosmotic medium (200 mOsm/L) to induce swelling. Tumor necrosis factor alpha (1.4 nM) and medium alone served as positive and negative controls, respectively. Western blots measured cytoplasmic phosphorylated or total FAK and PKB. EMSAs measured nuclear AP-1. All experiments were performed in triplicate.

RESULTS

Exposure to hypoosmotic stress resulted in activation of the following signaling messengers in a sequential fashion: (1) phosphorylation of FAK occurred by 2 min, (2) phosphorylation of PKB occurred by 10 min, (3) nuclear translocation of AP-1 occurred by 30 min. All three signaling events were abolished when these cells were pretreated with cytochalasin D.

CONCLUSION

Actin reorganization following hypoosmotic stress is essential for the FAK-mediated activation of the PI-3-K/PKB/AP-1 proliferative cascade. These data delineate a possible mechanism by which the cell swelling-induced cytoskeletal changes can initiate proliferative signal transduction in human liver cancer.

Alterations in intrahepatic hemodynamics of the harvested porcine liver

Hemodynamic properties of a donor liver, during initial reperfusion, are associated with the degree of graft preservation injury and have been proposed to correlate with subsequent markers of liver function. In the present study, hepatic hemodynamics, that is, portal venous pressure, hepatic vascular resistance, and compliance (vascular distensibility), were characterized (1) in situ before porcine livers were manipulated, (2) after these same livers were isolated and perfused within a bypass circuit, and (3) on reperfusion after 2 hours of cold ischemia. Hepatic vascular resistance was determined in each of these three states from the portal vein pressure response to differing hepatic blood flows. In addition, the response of the same livers to norepinephrine and nitroprusside was evaluated in each condition. In the in situ and isolated perfused liver, portal venous pressure increased only modestly despite doubling of hepatic flows. After cold ischemia, the pressure response to higher flows was significantly greater and much less of a reduction in hepatic vascular resistance was noted than in studies prior to cold ischemia. Unlike livers prior to cold ischemia, the pressure response to norepinephrine was attenuated following cold ischemia. The response to nitroprusside, however, remained intact reducing the portal pressure to that of in situ livers. Therefore the portal hypertension that follows cold ischemia appears to be largely provoked by the preservation injury and not by surgical manipulation or the bypass circuit. This increment in portal pressure is responsive to a nitric oxide donor.

Hypoosmotic stress stimulates growth in HepG2 cells via protein kinase B-dependent activation of activator protein-1

Although hypoosmotic stress-induced cell swelling activates phosphatidylinositol-3-kinase, its impact on the downstream signal protein kinase B and cell growth is unknown. Activator protein-1 is in part phosphatidylinositol-3-kinase dependent, and is important in proliferation. We hypothesized that cell swelling modulates proliferation in HepG2 cells via the protein kinase B-dependent activation of activator protein-1. HepG2 cells pretreated with or without LY294002 were exposed for up to 30 minutes to hypoosmotic medium (160 mOsm/L). Tumor necrosis factor-alpha (1.4 nmol/L) or normoosmolar medium (270 mOsm/L) served as positive and negative controls, respectively. Western immunoblots measured cytoplasmic phosphorylated and total protein kinase B. Electromobility shift assays measured nuclear activator protein-1. Methylene blue assays measured cell proliferation at 24, 48, and 72 hours after stimulation. Hypoosmotic stress phosphorylated protein kinase B by 10 minutes. Subsequently, hypoosmotic exposure stimulated activator protein-1 by 30 minutes. Pulse exposure to hypoosmotic stress potentiated HepG2 proliferation by 72 hours as compared to both negative controls and LY-inhibited cells (n = 4 per group, P = 0.009 and P = 0.004, respectively; P <0.001 analysis of variance. All three activation events were abolished with LY294002 pretreatment. In HepG2 cells, hypoosmotic stress-induced swelling stimulates proliferation via protein kinase B-mediated activation of activator protein-1. These data delineate a possible mechanism linking changes in cell volume to growth in human liver cancer.