Patients' and health professionals' understanding of and preferences for graphical presentation styles for individual-level EORTC QLQ-C30 scores.

PURPOSE: To investigate patients' and health professionals' understanding of and preferences for different graphical presentation styles for individual-level EORTC QLQ-C30 scores. METHODS: We recruited cancer patients (any treatment and diagnosis) in four European countries and health professionals in the Netherlands. Using a questionnaire, we assessed objective and self-rated understanding of QLQ-C30 scores and preferences for five presentation styles (bar and line charts, with or without color coding, and a heat map). RESULTS: In total, 548 patients and 227 health professionals participated. Eighty-three percent of patients and 85 % of professionals self-rated the graphs as very or quite easy to understand; this did not differ between graphical presentation styles. The mean percentage of correct answers to questions objectively assessing understanding was 59 % in patients, 78 % in medical specialists, and 74 % in other health professionals. Objective understanding did not differ between graphical formats in patients. For non-colored charts, 49.8 % of patients did not have a preference. Colored bar charts (39 %) were preferred over heat maps (20 %) and colored line charts (12 %). Medical specialists preferred heat maps (46 %) followed by non-colored bar charts (19 %), whereas these charts were equally valued by other health professionals (both 32 %). CONCLUSION: The substantial discrepancy between participants' high self-rated and relatively low objective understanding of graphical presentation of PRO results highlights the need to provide sufficient guidance when presenting such results. It may be appropriate to adapt the presentation of PRO results to individual preferences. This could be facilitated when PROs are administered and presented to patients and health professionals electronically.

Augmentation in anterior cruciate ligament reconstruction-a histological and biomechanical study on goats.

We studied reconstruction of the anterior cruciate ligament (ACL) in skeletally mature goats. In one group, the autogenous tissue was augmented with polydioxanone (PDS), the other group had no augmentation. Histological complete incorporation and remodeling of the transplant was found in both groups. The newly formed connective tissues gradually assumed the microscopic properties of the normal ligament. The augmented group showed a delay in remodeling and maturation of the fiber bundles. Mechanically, the PDS-augmented transplants were stronger than the nonaugmented transplants immediately after surgery. During the first 6 weeks, a rapid decrease in strength of the augmented transplants was found, whereas the strength of the nonaugmented group gradually increased. The results of our experiment do not favor augmentation of autografts in reconstruction of the ACL.

Developmental aspects of the rat endolymphatic sac and functional implications.

The purpose of this study was to determine specific characteristics of endolymphatic sac (ES) cells of the developing rat that are considered to be involved in endolymph homeostasis. Because intermediate filament proteins (IFPs) are regarded as markers of cell differentiation and basal lamina proteins (BLPs) are essential in cell<=>matrix interactions, we determined the presence of IFPs [cytokeratins (CKs) and vimentin] and BLPs [collagen IV, heparan sulphate proteoglycan (HSPG) and laminin] at different developmental stages before and after birth. In addition, we studied the expression of two enzymes of oxidative metabolism: cytochrome oxidase and succinate dehydrogenase. The presence of CKs 8, 18 and 19 in all epithelial cells of the ES during the embryonic stage is characteristic of simple (glandular) epithelial cells. Interestingly, a distinct population of these cells shows additional expression of CK 7, which is a feature of secretory cells. These CK 7-positive cells also contain a high concentration of oxidative enzymes and are rich in mitochondria, indicating that they are light cells. It is suggested that light cells possess specific energy-requiring transport capabilities. Loss of CK 19 expression in the distal part and in a large region of the intermediate part of the ES implies that these cells do not differentiate any further and acquire the capacity to proliferate. Furthermore, prominent co-expression of vimentin with the CKs in the distal part of the ES may confer viscoelastic properties on this epithelium. This may facilitate expansion and thus enable cushioning of pressure fluctuations. Finally, the early prominent occurrence of HSPG in the basal lamina of the ES enables transport of ions. In this light our recent observations of early functioning NaK-ATPases in certain ES cells are interesting.

Occurrence of NaK-ATPase isoforms during rat inner ear development and functional implications.

This study examined the presence of NaK-ATPase isoforms in the developing inner ear of the rat and studied the importance of functional subunit combinations in endolymph homeostasis. The findings were: (a) the combination alpha 1 beta 1 is found in epithelial, mesenchymal, and neural inner ear cells with an early starting expression 14 days postconception (dpc) in some endolymphatic sac cells; (b) from 1 day after birth (dab) expression of alpha 1 beta 2 is observed in marginal cells, vestibular dark cells, and certain vestibular nonsensory cells; (c) a transient expression of alpha 2 beta 1 is found in suprastrial fibrocytes and spiral ligament fibrocytes type II between 10 and 15 dab; (d) starting at 16 dpc the combination alpha 3 beta 1 is uniquely expressed in inner ear neural cells (as in other neural tissues). In conclusion, during development a switch from alpha 2 beta 1 towards alpha 1 beta 1 is observed in suprastrial fibrocytes and in spiral ligament fibrocytes type II. Thus, according to the biochemical characteristics of these combinations, a switch towards a NaK-ATPase with higher capacity takes place. In addition, prominent expression of the alpha 1 beta 2 combination in predominantly K+ ion transporting marginal and dark cells is in accordance with the characteristic of this combination and thus with the presumed function of these cells as important K+ suppliers for the endolymph. We believe this combination in certain vestibular nonsensory cells to be involved in K+ sensing. Early expression of the alpha 1 beta 1 combination in the endolymphatic sac, prior to that in the other parts of the inner ear, suggests that this structure may be involved to some extent in the development of the vestibulum and cochlea.

Middle ear effusions and structure of the tympanic membrane.

OBJECTIVE: To study the effect of various middle ear effusions on the structure of the lamina propria of the tympanic membrane. METHODS: Sterile and infective middle ear effusions were induced by obstruction of the eustachian tube in specific pathogen-free (SPF) rats and in rats with upper airway infections (URI), respectively. The condition of the tympanic membrane was monitored at regular intervals. After varying survival times, the animals were killed and the tympanic membranes processed for light and electron microscopy. RESULTS: Sterile effusions always resulted in tympanosclerotic lesions. These lesions did not develop in the presence of primary-infected effusions. These effusions had a severe destructive effect on the lamina propria, followed by fibrosis. Generally, secondary infection did not markedly affect preexisting tympanosclerotic lesions. Moreover, calcification disappeared when re-aeration of the middle ear occurred, but the abnormal collagen depositions persisted. CONCLUSIONS: Both sterile and infective effusions result in comprehensive irreversible changes in the lamina propria of the pars tensa. The development of tympanosclerosis is confined to sterile effusions. Mechanical injury and compromised vascularization of the lamina propria are likely to be important etiological factors in the development of tympanosclerosis.

Rat eustachian tube and its musculature.

The objective of this study was to evaluate the anatomy of the eustachian tube (ET) of the rat and the paratubal musculature. Microdissection and serial sections were used. The ET consists of collapsible membranous and membranocartilaginous segments and a noncollapsible bony segment. Tubal muscles are attached to the collapsible part; the salpingopharyngeus muscle (SPM) is well developed and consists of 3 distinct groups of muscle fibers; the tensor veli palatini muscle (TVPM) consists of 2 functionally different groups of fibers, but only 1 group assists in opening the ET. Attachment of the fibers of the SPM and TVPM that are involved in tubal opening is confined to the dorsal portion of the ET. This finding, together with the earlier observation that this part is mainly lined by squamous epithelium, strongly suggests that the dorsal part has a ventilatory function. The ventral portion of the ET, which is lined by ciliated-secretory epithelium and lacks the attachment of muscle fibers that can dilate the lumen, is assumed to serve clearance. The anatomic position of the levator veli palatini muscle suggests that this muscle contributes to the protective function of the ET. These findings are discussed with regard to the ET in humans.

Nature of the tympanic membrane insertion into the tympanic bone of the rat.

The nature of the insertion of the tympanic membrane into the tympanic bone was studied in the rat during the developmental period ranging from 18 days post conception (dpc) to 40 days after birth (dab). Techniques applied were light microscopy, electron microscopy and immunohistochemistry with antibodies to cytoskeletal proteins: vimentin, desmin and alpha-smooth muscle actin (sma) as fibroblast differentiation markers. It was established that the cartilaginous annulus of the pars tensa was connected to the tympanic bone by an interface of specialised connective tissue. Both the fibrocartilage and the interface were derived from the embryonal mesenchyme between the tympanic ring and meatal plate. Electron microscopy showed that the interface was composed of two types of fibroblast. The majority of these cells were myofibroblasts, which were interconnected by junctions and had intimate contact with the collagenous fibres. A small number were identified as genuine fibroblasts. Cytoskeletal characterisation revealed the presence of three types of cell: V cells which expressed vimentin, VA cells which expressed vimentin and alpha-sma and VAD cells which expressed vimentin, alpha-sma and desmin. The myofibroblasts expressed antigens of both smooth muscle cells (alpha-sma, desmin) and connective tissue cells (vimentin). It is suggested that the pars tensa is connected to the tympanic bone by a network of contractile cells and fibres. Contraction will move the membrane in an outward direction and antagonise the inward retraction by the tensor tympani.

Expression of intermediate filament proteins in benign lesions of the oral mucosa.

Immunohistochemistry with monospecific antibodies was used to study the expression patterns of cytokeratins (Cks) and vimentin in non-dysplastic lesions of the oral cavity, including lichen planus and fibromas. In hyperplastic lesions, Ck expression did not deviate significantly from the normal non-keratinizing squamous epithelium of the oral cavity. Hyperkeratotic lesions showed pronounced aberrations in their Ck profile. These lesions were characterized by extended expression of the keratinization marker Ck 10, the basal cell Ck 14 and the hyperproliferation-associated Ck 16 in the suprabasal compartment. The stratification markers Cks 4 and 13 showed a decreased expression. Coexpression of Cks and vimentin was found in lesions having accumulations of inflammatory cells in the subepithelial cell layer. These changes are felt to characterize benign mucosal lesions without dysplasia and might be helpful for distinguishing these lesions from potentially malignant ones.

Development of the tubotympanum in the rat.

OBJECTIVE: To investigate the relationship between the anatomical maturation of the middle ear and that of the eustachian tube and paratubal muscles in the rat. DESIGN: Wistar rats ranging from gestational day 12 to postnatal day 40 were used. METHODS: Tissue specimens were examined with routine light microscopy and electron microscopy. Epithelial differentiation was studied immunohistochemically with antibodies to different cytokeratins. RESULTS: The epithelial lining of the tubotympanum showed differentiation-related cytokeratin expression throughout the whole developmental period. The mucociliary epithelium reached mature features around birth. A dorsal extension and its framing cartilage started forming around 5 days after birth. This extension became lined by stratified nonciliated epithelium and attained maturity around 10 days after birth concurrently with the attachment of the dilatory muscles. This process was immediately followed by aeration of the middle ear cavity. CONCLUSIONS: The continuous expression of cytokeratins demonstrates that the epithelial lining of the tubotympanum is only derived from the embryonal endoderm. Furthermore, this study demonstrates that the eustachian tube shows a two-stage postnatal development. First, the mucociliary system matures, providing protection/clearance when the animal starts respiration and swallowing. Subsequently, the dorsal part attains maturity. The features of the epithelial lining of the dorsal part of the eustachian tube and the coincidence of the maturation of this part with the attachment of the dilating muscle fibers and the aeration of the middle ear indicates that this part provides ventilation. These findings support the authors' hypothesis that different parts of the eustachian tube serve different purposes: clearance, protection and ventilation.

Efficacy of Curosurf in a rat model of acute respiratory distress syndrome.

Curosurf, a natural lung surfactant, is considered a potential candidate for improving the treatment of acute respiratory distress syndrome (ARDS). To investigate this in a rat model of early-stage ARDS, Curosurf (62.5, 125 or 250 mg x kg(-1)) was administered by intratracheal bolus at 10 or 24 h following an intratracheal lipopolysaccharide (LPS; 1.6 mg x kg(-1)) challenge. Survival, respiratory frequency (fR), lung wet weight (LWW), total protein and cell differentiation in bronchoalveolar lavage fluid (BALF) were assessed. Curosurf treatment at 10 h after LPS challenge resulted in 100% survival at both 62.5 and 125 mg x kg(-1); at a dose of 250 mg x kg(-1) administered at 10 h after LPS, 1 out of 6 animals died. At a dose of 125 mg x kg(-1) Curosurf administered at 24 h after LPS, 1 out of 6 animals died. In contrast, only 35% of animals survived when not treated with Curosurf. Curosurf treatment resulted in an improved fR and in a significantly decreased LWW, total protein and number of polymorphonuclear cells in BALF. In conclusion, Curosurf treatment improved respiratory frequency and decreased mortality, pulmonary oedema and inflammation. As the decreased mortality was observed in spontaneously breathing nonoxygenated animals, the results cannot be extrapolated to human artificially ventilated acute respiratory distress syndrome patients with the expectation of a decreased mortality. The results suggest, however, that Curosurf may be an important therapeutic measure in early-stage acute respiratory distress syndrome.

Toxicokinetics of sulfur mustard and its DNA-adducts in the hairless guinea pig.

In order to provide a quantitative basis for pretreatment and therapy of intoxications with sulfur mustard (SM) the toxicokinetics of this agent as well as its major DNA-adduct were studied in male hairless guinea pigs for the intravenous, respiratory and percutaneous routes. The study comprised measurement of the concentration-time course of SM in blood and measurement of the concentrations of intact SM and its adduct to guanine in various tissues at several time points after administration of, or exposure to SM. SM was analyzed in blood and tissues by gas chromatography with automated thermodesorption injection and mass-spectrometric detection. DNA-adducts were measured via an immuno-slot-blot method. In contrast with nerve agents of the phosphofluoridate type, SM partitions strongly to various organs, especially the lung, spleen, liver and bone marrow. The respiratory toxicity of SM appears to be local, rather than systemic. Surprisingly, the maximum concentration of SM in blood upon percutaneous exposure to 1 LCt50 (10,000 mg.min.m-3, estimated) is approximately 6-fold higher than that for nose--only exposure to 3 LCt50 (2,400 mg.min.m-3). Pretreatment of hairless guinea pigs with the potential scavengers N-acetyl cysteine or cysteine isopropyl ester did not significantly increase the LCt50-value for nose--only exposure to SM vapor.

Intratracheal aerosolization of endotoxin (LPS) in the rat: a comprehensive animal model to study adult (acute) respiratory distress syndrome.

The aim of the study was to extend existing evidence that intratracheal aerosolization of LPS may serve as a very relevant model to study ARDS. The authors investigated the sequence of pathogenic events reflected by changes in levels of tumor necrosis factor alpha (TNF alpha), surfactant-associated protein A (SP-A) in BAL fluid, in addition to cell count, edema formation, and respiratory function. Within 24 h following intratracheal aerosolization of LPS in the rat, ARDS could be diagnosed according to the lung injury score for patients. This score includes the extent of the inflammatory density on chest X-rays, the severity of hypoxemia, the decline in lung compliance, and the level of PEEP (positive end expiratory pressure). In addition, other typical features of human ARDS appeared to be present in this model: (1) increased microvascular permeability reflected by edema, elevated levels of protein and of LDH, and increased numbers of PMNs in BAL fluid; (2) high levels of TNF alpha in BAL fluid preceding the appearance of PMNs; (3) changes in breathing pattern and a gradual development of respiratory failure with decreased compliance. SP-A levels in BAL fluid doubled within one hour after LPS administration, suggesting that this collectin may play a role in the immediate inflammatory response. Taken together, the findings presented here suggest that intratracheal LPS administration mimics the clinical development of ARDS very closely.

Cytokeratin and vimentin expression in normal epithelium and squamous cell carcinomas of the larynx.

The immunohistochemical expression patterns of cytokeratin polypeptides and vimentin were investigated in normal epithelia and squamous cell carcinomas of the larynx with special emphasis on tumor grading. During malignant transformation of epithelial cells, the cytokeratin expression patterns changed, depending on the differentiation grade of the carcinomas. In low-grade carcinomas, the expression patterns were close to those of the normal epithelium. With increasing tumor grade, there was decreased expression of stratification cytokeratins and increased expression of basal cell, simple cell and hyperproliferation-related cytokeratins. Increasing tumor grade was also associated with the expression of vimentin, a cytoskeletal protein of mesenchymal cells. No relationship was found between vimentin expression and the presence of lymph-node metastases.

Keratinocyte differentiation in acquired cholesteatoma and perforated tympanic membranes.

OBJECTIVE: To evaluate the type of differentiation of keratinocytes of acquired cholesteatoma and its significance for cholesteatoma invasiveness. DESIGN: Forty acquired cholesteatomas and 10 tympanic membranes with persisting perforations were snap frozen and processed for immunohistochemical studies. Cytokeratin antibodies that represented all subgroups and antibodies that were directed against collagen components of the basal lamina were applied. Expression of these constituents was scored by using light microscopy. RESULTS: The phenotype of the matrix was generally characterized by an extension of expression of basal cell cytokeratin 14 and hyperproliferation-associated cytokeratins 6, 16, and 17 into the suprabasal cell layers, while the expression of keratinization marker cytokeratin 10 was down-regulated. These features varied greatly at different sites of the matrix and were most marked at the advancing front of the cholesteatoma. A comparable expression pattern, but less pronounced, was observed at the epidermal front of the mucocutaneous junction of the tympanic membrane perforations. This phenomenon was invariably associated with a mononuclear cell infiltrate in the dermis at both junctions. The basal lamina was always intact. CONCLUSIONS: Acquired cholesteatomas show hyperproliferative features. There is a striking similarity between the pronounced expression of this phenotype and the associated inflammation at the mucocutaneous junctions of cholesteatomas and tympanic membrane perforations and those that are observed after epidermal injury. This indicates that epidermis and middle ear epithelium do not form stable junctions and the front can be considered to be a persisting epidermal defect. This involves the permanent presence of "activated keratinocytes" in the junction area that will lead to proliferation and migration, when additional triggers are present.

Macrophage subpopulations and RPE elimination in the pathogenesis of experimental autoimmune pigment epithelial protein-induced uveitis (EAPU).

Experimental autoimmune pigment epithelial protein-induced uveitis (EAPU) is a new type of disease that destroys the retinal pigment epithelium (RPE), and exhibits a hitherto unknown form of progressive chorioretinal dystrophy in which neuroretinal inflammatory foci are absent. The present study was aimed at studying the expression of adhesion molecules, and the kinetics of the appearance of the main types of macrophages and other intraocular immunocompetent cell populations in the various stages of this disease. EAPU was evoked in Lewis rats by immunization with the membrane protein from bovine RPE cells containing PEP-65 as main constituent. In the uvea, increased expression of intercellular adhesion molecule-1, of class II major histocompatibility complex antigen, and of ED2 macrophage reactivity were observed closely before the onset of EAPU. Expression of these reactivities was also slightly elevated by injections of the applied adjuvants alone. The onset of EAPU was mainly characterized by initial uveal infiltrations of ED1+ macrophages and a minor population of CD4 T cells, and an increase in ED3, ED7 and perivascular ED2 reactive macrophages. This was followed by the development of focal accumulations of ED1+ cells at both sides of the Bruch's membrane-RPE layer (Dálen-Fuchs nodules) which was permeated and disintegrated at these sites. The outer choroidal layer, the anterior iridal surface, and the base of the ciliary body more frequently contained active inflammatory cells than the other uveal areas. Lymphoid cells were found scattered through the uvea, aqueous and vitreous. The sites of increased activity of ED2+ and ED3+ cells in the uvea were rather similar to those of ED1 macrophages in the various stages of EAPU. Starting from multiple foci, the process of the formation of plaque-shaped cell accumulations in severe EAPU progressed along the RPE and exhibited a chronic character. The results of this study show that ED1+, ED2+, ED3+ and ED7+ subpopulations of macrophages are actively involved in an immunopathological process in which the RPE is the target. The thickening of the plaque-shaped cell accumulations stops if the integrity of all RPE cells at that site has been affected. We postulate that this is the result of antigen elimination while additional influence of the abrogation of RPE cytokine production is presumed.

Epidermal differentiation in the human external auditory meatus.

The differentiation of epidermis in the various parts of the human ear canal was documented on the basis of cytokeratin (Ck) expression patterns. Immunohistochemistry was performed on cryostat sections of normal meatal skin using a comprehensive panel of monospecific Ck antibodies representing the main lines of epithelial differentiation. The epidermis of the cartilaginous part showed a Ck profile characteristic of normal skin type differentiation. The deep meatal skin, including the tympanic membrane, showed a peculiar type of differentiation: in addition to epidermal Cks, hyperproliferation-associated Cks 6, 16, and 17 were expressed in the suprabasal cells, while the simple epithelia cell marker Ck 19 was found in the basal cells. The presence of hyperproliferative Cks in the deep meatal skin could only partly be related to areas of proliferative activity. Keratinocytes, which express markers of hyperproliferation, are migratory. Therefore, their presence in the meatal skin is likely to be related to the peculiar pattern of keratinocyte migration, the purpose of which is to keep the meatus free from desquamation products.

Squamous metaplasia of the middle ear epithelium.

This study deals with the expression of cytokeratins (Cks) in squamous cell metaplastic lesions in rat and human middle ear. In rats, squamous metaplastic lesions could be induced during chronic otitis media. The histological features of these lesions were similar to those observed in the human middle ear. Immunohistochemistry revealed that squamous cell metaplasia in both rat and human middle ear is characterised by a loss of simple epithelial cell related Cks and the appearance of Cks characteristic of stratified and cornifying epithelia. This indicates a true change in the differentiation of the middle ear epithelium. It is concluded that the Ck profile of the cholesteatoma matrix cannot be used as a variable to decide whether the origin of cholesteatomas is epidermal or metaplastic. This rat model is suitable for studying squamous cell metaplasia in relation to cholesteatoma genesis.

Cytokeratin and vimentin expression in normal epithelium and benign lesions of the vocal cords.

The expression of cytokeratins and vimentin was studied immunohistochemically in normal epithelium and 12 benign lesions of the vocal cord with the use of a broad panel of monoclonal antibodies against cytokeratins and vimentin. Histology showed that the various lesions contained hyperkeratotic, hyperplastic and atrophic epithelium, irrespective of their clinical appearance. Especially the Ck profile of the (hyper)keratotic lesions was changed in comparison with the native epithelium. Increased expression of the keratinization marker Ck 10 was associated with decreased expression of the stratification markers Cks 4 and 13. Expression of the basal cell marker Ck 14 and hyperproliferation-associated Cks 16 and 17 was increased in all the benign lesions, except in atrophic epithelium. These expression patterns differ from those observed in malignant epithelial lesions. The latter show a marked expression of simple cell Cks and vimentin and more pronounced expression of hyperproliferation-associated markers than the benign lesions.

Distribution and features of melanocytes during inner ear development in pigmented and albino rats.

In this developmental study, the distribution and features of melanocytes in the inner ear of pigmented and albino rats was investigated with the use of an antibody, which specifically reacts with a melanocyte differentiation antigen present in the membranes of (pre)melanosomes. Melanocyte precursors could be traced from 13 days post conception onwards and the course was followed to their targets in the inner ear. Melanocytes which settle in the modiolus appeared to reach their target along another pathway than strial and vestibular melanocytes. No difference was observed in the melanocyte distribution between pigmented and albino rats. The integration of melanocytes into the stria vascularis was associated with an increased rate of melanosome production in both strains, but in the albinos far fewer melanosomes were produced. After the stria had reached maturity, melanosome production was arrested and melanosomes were subject to lysosomal digestion. In the stria of the pigmented rats, cells with aggregations of disintegrating melanosomes appeared and persisted into adulthood. In the adult, the majority of the intermediate cells contained only a few scattered melanosomes, while melanosomes could only rarely be detected in the albinos. These observations indicate that there is a close relationship between melanosome production and the process of interdigitation of melanocytes with the marginal cells. It seems unlikely that melanosomes or melanin make any important contribution to the function of the adult stria vascularis. Outside the stria, the features of melanocytes in both strains were similar to skin melanocytes.