Case report: waardenburg syndrome

PURPOSE

A case of Waardenburg syndrome type 1 is described and relevant literature is reviewed to raise awareness about this rare syndrome, including the classification of each subtype and the differentiating clinical manifestations.

CASE REPORT

A 44-year-old African-American female presented for a routine evaluation with hearing loss, dystopia canthorum (W index = 2.74), and almost complete gray hair. In addition, she presented with heterochromia irides, different fundus pigmentation between eyes. The patient did not have any upper limbs defect, cranial skeletal abnormalities, or intestinal disorders.

CONCLUSION

Facial abnormalities and a white forelock are prominent features difficult to overlook during a routine ophthalmological examination. A careful medical history in patients with suspected Waardenburg syndrome is important to accurately classify this rare condition and to identify potential systemic implications associated to each subtype. The associated systemic complications can be addressed and managed through referral to the appropriate subspecialties.

Hearing Loss and Tinnitus in Military Personnel with Deployment-Related Mild Traumatic Brain Injury

The objective of this study was to analyze differences in incidence and epidemiologic risk factors for significant threshold shift (STS) and tinnitus in deployed military personnel diagnosed with mild traumatic brain injury (mTBI) due to either a blast exposure or nonblast head injury. A retrospective longitudinal cohort study of electronic health records of 500 military personnel (456 met inclusion criteria) diagnosed with deployment-related mTBI was completed. Chi-square tests and STS incidence rates were calculated to assess differences between blast-exposed and nonblast groups; relative risks and adjusted odds ratios of developing STS or tinnitus were calculated for risk factors. Risk factors included such characteristics as mechanism of injury, age, race, military occupational specialty, concurrent diagnosis of posttraumatic stress disorder (PTSD), and nicotine use. Among blast-exposed and nonblast patients, 67% and 58%, respectively, developed STS, (P=.06); 59% and 40%, respectively, developed tinnitus (P<.001). Incidence of STS was 24% higher in the blast-exposed than nonblast group. Infantry service was associated with STS; Marine Corps service, PTSD, and zolpidem use were associated with tinnitus. Unprotected noise exposure was associated with both STS and tinnitus. This study highlights potential risk factors for STS and tinnitus among blast-exposed and nonblast mTBI patient groups.

A Performance Comparison of Color Vision Tests for Military Screening

BACKGROUND

Current color vision (CV) tests used for aviation screening in the U.S. Army only provide pass-fail results, and previous studies have shown variable sensitivity and specificity. The purpose of this study was to evaluate seven CV tests to determine an optimal CV test screener that potentially could be implemented by the U.S. Army.

METHODS

There were 133 subjects [65 Color Vision Deficits (CVD), 68 Color Vision Normal (CVN)] who performed all of the tests in one setting. CVD and CVN determination was initially assessed with the Oculus anomaloscope. Each test was administered monocularly and according to the test protocol. The main outcome measures were test sensitivity, specificity, and administration time (automated tests).

RESULTS

Three of the four Pseudoisochromatic Plate (PIP) tests had a sensitivity/specificity > 0.90 OD/OS, whereas the FALANT tests had a sensitivity/specificity > 0.80 OD/OS. The Cone Contrast Test (CCT) demonstrated sensitivity/specificity > 0.90 OD/OS, whereas the Color Assessment and Diagnosis (CAD) test demonstrated sensitivity/specificity > 0.85 OD/OS. Comparison with the anomaloscope ("gold standard") revealed no significant difference of sensitivity and specificity OD/OS with the CCT, Dvorine PIP, and PIPC tests. Finally, the CCT administration time was significantly faster than the CAD test.

DISCUSSION

The current U.S. Army CV screening tests demonstrated good sensitivity and specificity, as did the automated tests. In addition, some current PIP tests (Dvorine, PIPC), and the CCT performed no worse statistically than the anomaloscope with regard to sensitivity/specificity. The CCT letter presentation is randomized and results would not be confounded by potential memorization, or fading, of book plates.

Assessment of an Alternative Army Aircrew Eyewear

BACKGROUND

Currently, Army aircrews needing refractive correction are issued the HGU-4/P aviator spectacles. However, a recently published survey found dissatisfaction with the current spectacle frame. The Aircrew Flight Frame (AFF) has been used by the Air Force for over 14 yr, with the AFF-OP (Operational) style used the longest. The purpose of this study was to evaluate AFF-OP performance and compatibility among U.S. Army aircrew under operational conditions.

METHODS

At 1-, 6-, and 12-wk intervals, 73 Army aircrew members wore the AFF-OP eyewear and completed a Likert scale survey. There were 14 outcome measures surveyed, with the main outcome measure being frame preference.

RESULTS

The AFF-OP was preferred significantly more than the HGU-4/P spectacle. Overall, 94% of aircrew responses preferred the AFF-OP and the three highest subjective reasons for AFF-OP preference were: 1) comfort around the ears without helmet or headset; 2) comfort around the ears with helmet or headset; and 3) the effect on ear cup seal. There were no statistically significant differences in responses over the three surveyed time intervals.

DISCUSSION

Army aviation aircrew preferred the AFF-OP over the current HGU-4/P spectacles. Two of the top three highest subjective reasons for AFF-OP preference coincided with two of the top three operational eyewear problems reported in the recently published survey. If Army aircrew do not wear their issued eyewear, they may purchase their own frame "out of pocket." However, this can lead to use of a frame that has not been tested for compatibility and may compromise performance of aircrew life support equipment.

Military aircrew eyewear survey: operational issues

BACKGROUND

Army aircrew are required to operate under stressful conditions within a degraded visual environment. To gain an understanding of current eyewear mission needs, we surveyed aircrew regarding operational issues associated with the current U.S. Army-issue aircrew eyewear.

METHODS

An anonymous online survey was completed by 976 U.S. Army aircrew personnel recruited through an invitational e-mail.

RESULTS

Of the respondents, 34% reported wearing corrective lenses. Nearly 50% of them reported dissatisfaction with the HGU-4/P Aviator spectacles. The leading problems reported were discomfort (15%), "hot spots" around the ears (13%), and break of the earcup seal (11%). Nearly 41% of the respondents wore multifocal lenses and, of those, 16% reported that the HGU-4/P's restricted field of view (FOV) adversely affected duty performance. Of those who wore Modified HGU-4/P Apache spectacles, 79% had an unacceptable FOV with the helmet display unit. A similar number of aircrew modified the Apache eyewear to increase the FOV. In addition, wind and dust created eye discomfort or affected the vision of 46% of all respondents when performing flight duties. Over 82% expressed the need for an improved aircrew spectacles and 73% desired aviation-compatible protective eyewear.

DISCUSSION

The current Army HGU-4/P Aviator and the Modified HGU-4/P Apache spectacles have significant operational deficiencies and compatibility issues. Such deficiencies have led to poor wear compliance and unauthorized modification of the Army-issue Aviator eyewear, posing readiness and safety issues. The results of this survey formally identify the need for military combat eye protection that is compatible with flight systems.

Dependence of corneal epithelial cell proliferation on modulation of interactions between ERK1/2 and NKCC1

Epidermal growth factor (EGF) receptor stimulation or protein kinase C (PKC) activation enhances corneal epithelial cell proliferation. This response is needed to maintain corneal transparency and vision. We clarify here in human corneal epithelial cells (HCEC) the cause and effect relationships between ERK1/2 and NKCC1 phosphorylation induced by EGF receptor or PKC activation. Furthermore, the roles are evaluated of NF-κB and ERK1/2 in mediating negative feedback control of ERK1/2 and NKCC1 phosphorylation through modulating DUSP1 and DUSP6 expression levels. Intracellular Ca(2+) rises induced by EGF elicited NKCC1 phosphorylation through ERK1/2 activation. Bumetanide suppressed EGF-induced NKCC1 phosphorylation, transient cell swelling and cell proliferation. This cause and effect relationship is similar to that induced by PKC stimulation. NKCC1 activation occurred through time-dependent increases in protein-protein interaction between ERK1/2 and NKCC1, which were proportional to EGF concentration. DUSP6 upregulation obviated EGF and PKC-induced NKCC1 phosphorylation. NF-κB inhibition by PDTC prolonged ERK1/2 activation through GSK-3 inactivation leading to declines in DUSP1 expression levels. These results show that EGF receptor and PKC activation induce increases in HCEC proliferation through ERK1/2 interaction with NKCC1. This response is modulated by changes in DUSP1- and DUSP6-mediated negative feedback control of ERK1/2-induced NKCC1 phosphorylation.

Epidermal growth factor receptor transactivation by the cannabinoid receptor (CB1) and transient receptor potential vanilloid 1 (TRPV1) induces differential responses in corneal epithelial cells

Corneal epithelial injury induces release of endogenous metabolites that are cannabinoid receptor 1 (CB1) and transient receptor potential vanilloid 1 (TRPV1) agonists. We determined the functional contributions by CB1 and TRPV1 activation to eliciting responses underlying wound healing in human corneal epithelial cells (HCEC). Both the selective CB1 and TRPV1 agonists (i.e., WIN55,212-2 [WIN] and capsaicin [CAP], respectively) induced EGFR phosphorylation whereas either inhibition of its tyrosine kinase activity with AG1478 or functional blockage eliminated this response. Furthermore, EGFR transactivation was abolished by inhibitors of proteolytic release of heparin bound EGF (HB-EGF). CB1-induced Ca(2+) transients were reduced during exposure to either the CB1 antagonist, AM251 or AG1478. Both CAP and WIN induced transient increases in Erk1/2, p38, JNK1/2 MAPK and Akt/PI-3K phosphorylation status resulting in cell proliferation and migration increases which mirrored those elicited by EGF. Neither EGF nor WIN induced any increases in IL-6 and IL-8 release. On the other hand, CAP-induced 3- and 6-fold increases, which were fully attenuated during exposure to CPZ, but AG1478 only suppressed them by 21%. The mixed CB1 and TRPV1 antagonist, AM251, enhanced the CAP-induced rise in IL-8 release to a higher level than that elicited by CAP alone. In conclusion, CB1 and TRPV1 activation induces increases in HCEC proliferation and migration through EGFR transactivation leading to global MAPK and Akt/PI-3K pathway stimulation. On the other hand, the TRPV1-mediated increases in IL-6 and IL-8 release are elicited through both EGFR dependent and EGFR-independent signaling pathways.

Transient receptor potential vanilloid 1 activation induces inflammatory cytokine release in corneal epithelium through MAPK signaling

In certain epithelial tissues, activation of transient receptor potential (TRP) vanilloid subtype 1 (TRPV1) by noxious stimuli induces pro-inflammatory cytokine release, which helps to mitigate the challenge. While the corneal epithelium elicits such responses to a variety of challenges, it remains unknown whether TRPV1 mediates pro-inflammatory cytokine secretion. Accordingly, we probed for TRPV1 expression and function in human (HCEC) and rabbit corneal epithelial cell (RCEC) lines, in their primary counterparts, and in human and mouse corneal epithelium in situ. Cell membrane and perinuclear TRPV1 expression was detected in all preparations and its identity verified by Western blot analysis. Capsaicin (CAP) (1-10 microM) increased nonselective cation channel whole cell currents (2.5-fold +/- 0.5-fold between -60 and 130 mV), resulting in calcium transients that were fully blocked by the TRPV1 antagonists capsazepine (CPZ) and ruthenium red, or removal of extracellular calcium. Another signaling event involved transient activation of global mitogen-activated protein kinase (MAPK) superfamily, which was followed by up to 3.3- and 9-fold increases in interleukins (IL)-6 and -8 release, respectively. Such increases in inflammatory mediators' release were suppressed by exposure to CPZ or MAPK inhibitors, or removal of Ca2+. Taken together, TRPV1 receptors may play a role in mediating corneal epithelial inflammatory mediator secretion and subsequent hyperalgesia.

Potassium-chloride cotransporter mediates cell cycle progression and proliferation of human corneal epithelial cells

Epidermal growth factor (EGF)-induced proliferation of corneal epithelial cells contributes to its renewal, which maintains the protective and refractive properties of the cornea. This study characterized in human corneal epithelial cells (HCEC) the role of the potassium-chloride cotransporter (KCC) in mediating (1) EGF-induced mitogen-activated protein kinase (MAPK) pathway activation; (2) increases in cell cycle progression; and (3) proliferation. The KCC inhibitor [(dihydroindenyl)oxy] alkanoic acid (DIOA) and KCC activator N-ethylmaleimide (NEM), suppressed and enhanced EGF-induced p44/42MAPK activation, respectively. Such selective modulation was mirrored by corresponding changes in cell proliferation and shifts in cell cycle distribution. DIOA induced a 20% increase in G(0)/G(1)-phase cell population, whereas NEM induced a 22% increase in the proportion of cells in the G(2)/M-phase and accelerated the transition from G(0)/G(1)-phase to the S-phase. Associated with these changes, KCC1 content in a plasma membrane enriched fraction increased by 300%. Alterations in regulatory volume capacity were associated with corresponding changes in both KCC1 membrane content and activity. These results indicate that EGF-induced increases in KCC1 activity and content modulate cell volume changes required for (1) activation of the p44/42MAPK signaling pathway, (2) cell cycle progression, and (3) increases in cell proliferation.

Characterization of regulatory volume behavior by fluorescence quenching in human corneal epithelial cells

An in-depth understanding of the mechanisms underlying regulatory volume behavior in corneal epithelial cells has been in part hampered by the lack of adequate methodology for characterizing this phenomenon. Accordingly, we developed a novel approach to characterize time-dependent changes in relative cell volume induced by anisosmotic challenges in calcein-loaded SV40-immortalized human corneal epithelial (HCE) cells with a fluorescence microplate analyzer. During a hypertonic challenge, cells shrank rapidly, followed by a temperature-dependent regulatory volume increase (RVI), tau(c) = 19 min. In contrast, a hypotonic challenge induced a rapid (tau(c) = 2.5 min) regulatory volume decrease (RVD). Temperature decline from 37 to 24 degrees C reduced RVI by 59%, but did not affect RVD. Bumetanide (50 microM), ouabain (1 mM), DIDS (1 mM), EIPA (100 microM), or Na(+)-free solution reduced the RVI by 60, 61, 39, 32, and 69%, respectively. K+, Cl- channel and K(+)-Cl(-) cotransporter (KCC) inhibition obtained with either 4-AP (1 mM), DIDS (1 mM), DIOA (100 microM), high K+ (20 mM) or Cl(-)-free solution, suppressed RVD by 42, 47, 34, 52 and 58%, respectively. KCC activity also affects steady-state cell volume, since its inhibition or stimulation induced relative volume alterations under isotonic conditions. Taken together, K+ and Cl- channels in parallel with KCC activity are important mediators of RVD, whereas RVI is temperature-dependent and is essentially mediated by the Na(+)-K(+)-2Cl(-) cotransporter (Na(+)-K(+)-2Cl(-)) and the Na(+)-K(+) pump. Inhibition of K+ and Cl- channels and KCC but not Na(+)-K(+)-2Cl(-) affect steady-state cell volume under isotonic conditions. This is the first report that KCC activity is required for HCE cell volume regulation and maintenance of steady-state cell volume.

Functional and molecular characterization of multiple K-Cl cotransporter isoforms in corneal epithelial cells

The dependence of regulatory volume decrease (RVD) activity on potassium-chloride cotransporter (KCC) isoform expression was characterized in corneal epithelial cells (CEC). During exposure to a 50% hypotonic challenge, the RVD response was larger in SV40-immortalized human CEC (HCEC) than in SV40-immortalized rabbit CEC (RCEC). A KCC inhibitor-[(dihydroindenyl)oxy] alkanoic acid (DIOA)-blocked RVD more in HCEC than RCEC. Under isotonic conditions, N-ethylmaleimide (NEM) produced KCC activation and transient cell shrinkage. Both of these changes were greater in HCEC than in RCEC. Immunoblot analysis of HCEC, RCEC, primary human CEC (pHCEC), and primary bovine CEC (BCEC) plasma membrane enriched fractions revealed KCC1, KCC3, and KCC4 isoform expression, whereas KCC2 was undetectable. During a hypotonic challenge, KCC1 membrane content increased more rapidly in HCEC than in RCEC. Such a challenge induced a larger increase and more transient p44/42MAPK activation in HCEC than RCEC. On the other hand, HCEC and RCEC p38MAPK phosphorylation reached peak activations at 2.5 and 15 min, respectively. Only in HCEC, pharmacological manipulation of KCC activity modified the hypotonicity-induced activation of p44/42MAPK, whereas p38MAPK phosphorylation was insensitive to such procedures in both cell lines. Larger increases in HCEC KCC1 membrane protein content correlated with their ability to undergo faster and more complete RVD. Furthermore, pharmacological activation of KCC increased p44/42MAPK phosphorylation in HCEC but not in RCEC, presumably a reflection of low KCC1 membrane expression in RCEC. These findings suggest that KCC1 plays a role in (i) maintaining isotonic steady-state cell volume homeostasis, (ii) recovery of isotonic cell volume after a hypotonic challenge through RVD, and (iii) regulating hypotonicity-induced activation of the p44/42MAPK signaling pathway required for cell proliferation.

Differential dependence of regulatory volume decrease behavior in rabbit corneal epithelial cells on MAPK superfamily activation

We characterized the dependence of hypotonicity-induced regulatory volume decrease (RVD) responses on mitogen-activated protein kinase (MAPK) pathway signaling in SV40-immortalized rabbit corneal epithelial cells (RCEC). Following calcein-AM loading, RVD was monitored using a microplate fluorescence reader. Western blot analysis determined MAPK activation. After 30 min, the RVD response restored the relative cell volume to nearly isotonic values, whereas it was inhibited when cells were bathed either in a Cl- -free solution or with the Cl- -channel inhibitors: 5-nitro-2-(3-phenylpropylamino)benzoic acid or niflumic acid. Similar declines occurred with either a high-K+ (20 mM) supplemented solution or the K+ channel inhibitor 4-aminopyridine. Activation of extracellular signal-regulated kinase (ERK), p38, and stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK) was time and tonicity-dependent. Stimulation of ERK and SAPK/JNK was maximized earlier than that of p38. Activation of ERK and SAPK/JNK was insensitive to Cl- and K+ channel inhibitors, whereas inhibition with either PD98059 or SP600125, respectively, blocked RVD. However, inhibition of p38 with SB203580had no effect on RVD. Suppression of RVD instead blocked p38 activation. Differences in the dependence of RVD activation on Erk1/2 and p38 signaling were validated in dominant negative (d/n)-Erk1 and d/n-p38 cells. Volume-sensitive Cl- and K+ channel activation contributes, in concert, to RVD in RCEC. Therefore, swelling-induced ERK and SAPK/JNK stimulation precedes Cl- and K+ channel activation, whereas p38 activation occurs as a consequence of RVD.

Phosphatase-mediated crosstalk control of ERK and p38 MAPK signaling in corneal epithelial cells

PURPOSE

To test the hypothesis that the protein phosphatases PP2A and MKP-1 are involved in controlling epidermal growth factor (EGF)-induced increases in rabbit corneal epithelial cell (RCEC) migration by mediating crosstalk between signaling pathways eliciting EGF receptor control of migration and proliferation.

METHODS

Western blot analysis was used to determine the phosphorylation status of Erk1/2, p38, and the mitogen-activated protein kinase (MAPK) kinase (MEK1/2) using inhibitors of Erk1/2 or p38 and dominant-negative (d/n) Erk1 or d/n p38 cell lines. Coimmunoprecipitation was used to evaluate protein phosphatase (PP)2A and Erk1/2 interaction. Short-interfering RNA (siRNA) transfection was performed to analyze the involvement of MAPK phosphatase (MKP)-1 in crosstalk. Scratch-wound assay was used to determine EGF-dependent effects on cell migration.

RESULTS

EGF (10 ng/mL) induced changes in activation of Erk1/2 and p38, which were enhanced by inhibition with 10 microM SB203580 and 10 muM PD98059, respectively. PP inhibition with sodium orthovanadate (100 microM), okadaic acid (10 nM), or Ro 31-8220 (10 microM) resulted in larger and more prolonged increases in the phosphorylation status of Erk1/2 and p38. After 1 hour, EGF induced 14-fold increases in MKP-1 protein expression. After MKP-1 siRNA transfection, EGF had induced a similar pattern of changes in the phosphorylation status in Erk1/2 and p38 following PP inhibition. EGF-induced cell migration was enhanced by Erk1/2 pathway inhibition and was accentuated after PP inhibition. Conversely, p38 pathway inhibition eliminated this response.

CONCLUSIONS

EGF-induced changes in Erk1/2 and p38 phosphorylation status are dependent on PP-mediated crosstalk. This control modulates the magnitude of growth factor-induced increases in corneal epithelial cell migration.

AsialoGM1-mediated IL-8 release by human corneal epithelial cells requires coexpression of TLR5

PURPOSE

In this study, it was determined that human corneal epithelial cells (HCECs) express asialoganglioside ganliotetraosylceramide (asialoGM1) and toll-like receptor (TLR)-5, and their interaction induces interleukin (IL)-8 release through Ca(2+) transient activation and mitogen-activated protein kinase (MAPK) stimulation.

METHODS

Expression of asialoGM1 and TLR5 was detected in SV40 HCECs by Western blot and flow cytometry analyses and their association by coimmunoprecipitation. Single-cell fluorescence imaging was used to measure intracellular free Ca(2+) transients in fura-2-loaded cells. The enzyme-linked immunosorbent assay (ELISA) was used to quantify IL-8 production in both cultured and primary HCECs.

RESULTS

The HCECs expressed both asialoGM1 and TLR5 receptors. Ligation of asialoGM1 resulted in protein-protein interaction with TLR5, followed by transient increases in Ca(2+) influx through L-type voltage-dependent Ca(2+) channels. This led to P2Y receptor stimulation along with membrane depolarization, resulting from increases in ATP release into the medium. Intracellular Ca(2+) transients led to time-dependent extracellular signal-regulated kinase (ERK) MAPK pathway stimulation, followed by a 9.5-fold increase in IL-8 release. Similarly, in primary HCECs, asialoGM1 receptor stimulation resulted in an 8.1-fold increase. With a TLR5 neutralizing antibody, no asialoGM1-induced increases in IL-8 release occurred, and this response was not suppressed in the presence of a TLR2 neutralizing antibody.

CONCLUSIONS

IL-8 release by HCECs is mediated through ligand-induced asialoGM1 protein-protein interactions with TLR5. This response is dependent on ATP efflux into the medium, followed by P2Y receptor stimulation. Such activation, in turn, results in increases in Ca(2+) influx through L-type voltage-dependent Ca(2+) channels, as well as stimulation of the ERK pathway.

Fate of hypertonicity-stressed corneal epithelial cells depends on differential MAPK activation and p38MAPK/Na-K-2Cl cotransporter1 interaction

The capacity of the corneal epithelium to adapt to hypertonic challenge is dependent on the ability of the cells to upregulate the expression and activity of cell membrane-associated Na-K-2Cl cotransporter1 (NKCC1). Yet, the signaling pathways that control this response during hypertonic stress are still unclear. We studied stress-induced changes in proliferation and survival capacity of SV40-immortalized human (HCEC) and rabbit (RCEC) corneal epithelial cells as a function of (i) the magnitude of the hypertonic challenge, (ii) differential changes in activation of mitogen-activated protein kinase (MAPK), and (iii) the extent of p38MAPK interaction with NKCC1. Cells were incubated in hypertonic (up to 600 mOsm) media for varying time periods up to 24 h. Phosphorylated forms of p44/42, p38, and stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK) MAPK were immunoprecipitated from cell lysates, and the amount of each activated NKCC1-associated MAPK was evaluated by Western blot/ECL assay. DNA integrity was assessed by electrophoresis in a 2% agarose gel. Cell survival and proliferation were evaluated based on three criteria: protein content, cell count, and the MTT assay. Exposure to media of 325-350 mOsm increased proliferation of HCEC up to 75%, whereas this response was limited to <16% in RCEC. At higher osmolarities, cell proliferation decreased in both species. SAPK/JNK activity increased 150-fold in HCEC and <10-fold in RCEC, while DNA fragmentation occurred only in HCEC. Compared to HCEC, the better RCEC survival rate was associated with higher p38MAPK activity and near complete restoration of p44/42MAPK activity after the first 30 min. In both cell lines, the amount of phospho-NKCC1 that coimmunoprecipitated with phospho-p38MAPK was proportional to the magnitudes of their respective activation levels. However, no such associations occurred between amounts of phosphorylated p44/42MAPK or SAPK/JNK and phospho-NKCC1. Under isotonic conditions, with bumetanide-induced inhibition of RCEC and HCEC NKCC1 activities, p44/42MAPK activity declined by 40 and 60%, respectively. Such declines led to proportional decreases in cell proliferation. Survival of hypertonicity-stressed corneal epithelial cells depends both on p38MAPK activation capacity and the ability of p38MAPK to stimulate NKCC1 activity through protein-protein interaction. The level of NKCC1 activation affects the extent of cell volume recovery and, in turn, epithelial survival capacity.