Systematic review of measurement tools to assess surgeons' intraoperative cognitive workload.

BACKGROUND: Surgeons in the operating theatre deal constantly with high-demand tasks that require simultaneous processing of a large amount of information. In certain situations, high cognitive load occurs, which may impact negatively on a surgeon's performance. This systematic review aims to provide a comprehensive understanding of the different methods used to assess surgeons' cognitive load, and a critique of the reliability and validity of current assessment metrics. METHODS: A search strategy encompassing MEDLINE, Embase, Web of Science, PsycINFO, ACM Digital Library, IEEE Xplore, PROSPERO and the Cochrane database was developed to identify peer-reviewed articles published from inception to November 2016. Quality was assessed by using the Medical Education Research Study Quality Instrument (MERSQI). A summary table was created to describe study design, setting, specialty, participants, cognitive load measures and MERSQI score. RESULTS: Of 391 articles retrieved, 84 met the inclusion criteria, totalling 2053 unique participants. Most studies were carried out in a simulated setting (59 studies, 70 per cent). Sixty studies (71 per cent) used self-reporting methods, of which the NASA Task Load Index (NASA-TLX) was the most commonly applied tool (44 studies, 52 per cent). Heart rate variability analysis was the most used real-time method (11 studies, 13 per cent). CONCLUSION: Self-report instruments are valuable when the aim is to assess the overall cognitive load in different surgical procedures and assess learning curves within competence-based surgical education. When the aim is to assess cognitive load related to specific operative stages, real-time tools should be used, as they allow capture of cognitive load fluctuation. A combination of both subjective and objective methods might provide optimal measurement of surgeons' cognition.

Antigen-initiated B-lymphocyte differentiation. VIII. Sedimentation velocity and buoyant density characterization of virgin antibody-forming cell progenitors in the adoptive immune response of unprimed CBA mice to 4-hydroxy-3-iodo-5-nitrophenylacetic acid-polymerized bacterial flagellin antigen.

The characteristics of antibody-forming cell (AFC) progenitors lacking previous contact with specific antigen (virgin AFC progenitors) has been studied using sedimentation velocity and buoyant density separation for the investigation of physically distinct B-cell subpopulations. Functional characterization of isolated subsets was made using a quantitative adoptive immune assay for the IgM AFC progenitors responding to the antigen 4-hydroxy-3-iodo-5-nitrophenylacetic acid conjugated polymerized bacterial flagellin. Extensive heterogeneity is present among B lymphocytes, only some subpopulations of which exhibit AFC progenitor function. In the spleen of adult conventional CBA mice, atypically fast sedimenting cells of low buoyant density are active, while typical small B lymphocytes do not appear to be progenitors of IgM AFC. Spleen of adult specific pathogen-free (SPF), germfree, and athymic nude mice give similar results, although a minor population of typical slowly sedimenting dense cells are active in the latter two sources. Adult conventional bone marrow cells are as physically and functionally heterogeneous as splenic B cells, and although a significant proportion of AFC progenitor activity is found among dense, slowly sedimenting cells, most of the activity is among low density, faster sedimenting cells. In contrast to this situation in adult animals, where most of the unprimed AFC progenitors are large, atypical B cells, the spleens of neonatal mice provide a site where virgin AFC progenitors with the physical properties of typical small B lymphocytes are found. While being present in conventional and SPF neonatal spleens, these virgin cells are predominant in 7-day-old germfree mouse spleen. These findings suggest that the newborn virgin B cell is a typical small lymphocyte. However, few cells of this type are found in the adult animal. The unprimed AFC-progenitor population in the adult consists of large, fast sedimenting, low buoyant density, adherent cells, the physical properties of which are characteristic of activated B lymphocytes. It is suggested that these atypical cells are derived from the small newborn virgin B cell by the nonspecific effects of environmental antigenic stimuli.

Induction of cell cycle regulatory proteins in anti-immunoglobulin-stimulated mature B lymphocytes.

Progression through the cell cycle is a tightly controlled process that integrates signals generated at the plasma membrane with the proteins that form the cell cycle machinery. The current study chronicles the induction of cyclins, cyclin-dependent kinases (cdk), and cdk inhibitors in low density primary mouse B lymphocytes after anti-immunoglobulin plus interleukin 4 (IgM + IL-4) stimulation. In this system, > 85% of cells remain in the G0/G1 phase of cell cycle for an initial 24-h period, followed by entry of up to 50% of the cells into S phase, commencing around 30 h and peaking at 48 h. Extensive time course analyses of these anti-IgM + IL-4-stimulated B cells revealed that the G1-associated D-type cyclins D2 and D3 were induced by 3 h after stimulation, and that cyclins E, A, and B were subsequently induced sequentially, beginning at mid-G1, G1/S transition, and S phase, respectively. The G1-associated cyclin D1 was not expressed at any stage of the anti-Ig + IL-4-induced B cell cycle. cdk2, cdk4, and cdk6 were induced during G1, whereas cell division cycle-2 (cdc2) was induced concomitantly with S phase. Irrespective of their expression, the kinases cdk2 and cdc2 were only active from S phase onwards, suggesting that productive cyclin/kinase complex formation did not occur until that time. Cell cycle inhibitors p21 and p19 were induced by anti-Ig + IL-4, peaking in expression at mid-G1 and S phase, respectively. Stimulation of low density B cells with anti-Ig + IL-4 caused rapid down regulation of the p27 inhibitor, however this protein was reexpressed at 54-96 h after stimulation. In contrast, B cells stimulated with anti-CD40, a stimulus which induces long-term B cell proliferation, permanently down regulated p27. These findings are consistent with the concept that p27 reexpression contributes to the G1 arrest that follows antigen receptor crosslinking. Low density B cells cultured in the viability-enhancing cytokine IL-4 alone also showed induction of D2 and D3 cyclin expression. However, the D2 expression was transient, and the D3 expression was substantially lower than that observed in B cells induced to proliferate by anti-Ig + IL-4. This partial induction of D2 and D3 expression may explain IL-4's ability to promote B cell entry into G1 but not S phase of cell cycle, and furthermore, its ability to truncate G1 progression when B cells are subsequently stimulated with anti-Ig.

Depletion of eosinophils in mice through the use of antibodies specific for C-C chemokine receptor 3 (CCR3).

We have generated rat monoclonal antibodies specific for the mouse eotaxin receptor, C-C chemokine receptor 3 (CCR3). Several anti-CCR3 mAbs proved to be useful for in vivo depletion of CCR3-expressing cells and immunofluorescent staining. In vivo CCR3 mAbs of the IgG2b isotype substantially depleted blood eosinophil levels in Nippostrongyus brasiliensis-infected mice. Repeated anti-CCR3 mAb treatment in these mice significantly reduced tissue eosinophilia in the lung tissue and bronchoalveolar lavage fluid. Flow cytometry revealed that mCCR3 was expressed on eosinophils but not on stem cells, dendritic cells, or cells from the thymus, lymph node, or spleen of normal mice. Unlike human Th2 cells, mouse Th2 cells did not express detectable levels of CCR3 nor did they give a measurable response to eotaxin. None of the mAbs were antagonists or agonists of CCR3 calcium mobilization. To our knowledge, the antibodies described here are the first mAbs reported to be specific for mouse eosinophils and to be readily applicable for the detection, isolation, and in vivo depletion of eosinophils.

Independently ligating CD38 and Fc gammaRIIB relays a dominant negative signal to B cells.

CD38 is expressed on a variety of hematopoietic cells and has a unique enzymatic activity that converts nicotinamide adenine dinucleotide (NAD) into cyclic ADP-ribose (cADPR) and then into ADPR. CD38 is expressed at increasingly higher levels on B cells at each stage of B cell differentiation, and is then down-regulated on germinal center B cells and mature plasma cells. Crosslinking of CD38 on the surface of mature, resting B cells induces B-cell proliferation, which is enhanced by co-signals such as IL-4 and LPS. CD38-induced proliferation is abrogated by Fc gammaRIIB ligation and this inhibition can be effected by the addition of anti-Fc gammaRII Ab midway through a 48 h in vitro culture indicating that it delivers a potent negative signal to CD38 activated B cells. The suppressive signal was shown to occur through the Fc gammaRIIB because CD38-induced B-cell activation was not inhibited by the ligation of Fc gammaRIIB in Fc gammaRII-deficient B cells. These results indicate that Fc gammaRIIB can act as a regulatory molecule that modulates CD38 signals in vivo.

Antigen-induced B lymphocyte differentiation.

The analysis of B-lymphocyte activation has been a tantalizing prospect for both immunologists and cell biologists, as B cells have the unique characteristics of possessing a well-characterized receptor and displaying a clear inducible response to a specific antigen. As outlined in this review, we now know much about the cellular events which occur when mature B cell encounters antigen within the peripheral lymphoid organ of an immunocompetent host. Our understanding of the molecular events associated with these cellular processes is currently limited, but such information will undoubtedly ensue. The greatest challenges remaining in B-cell immunology are immunoregulation and an understanding of how the enormous B-cell specificity repertoire is generated. These challenges require greater insight into lymphocyte triggering events and the early events in B-cell maturation. This review has not restricted itself to the phenomena associated with antigen-triggered mature splenic B cells, but has attempted to include aspects of B-cell development which are often overlooked or disregarded. In particular, attention has been drawn to certain nonspecific antigen-induced B-cell events, and to antigen-initiated developmental processes which precede mature B-cell development. Additionally, the commitment of triggered mature B cells to effector cell production has been reconsidered in light of current attempts to propagate normal lymphocytes continuously and in a manner which avoids terminal differentiation. The availability of such lines, together with increasingly refined technology, will hopefully allow us to resolve the remaining mysteries in B-cell development.

Antigen-initiated B lymphocyte differentiation: non-specific stimulation changes the physical properties of virgin AFC-progenitors in neonatal mouse spleen.

While the virgin AFC-progenitors for an adoptive immune response in neonatal germ-free CBA mouse spleen are small, dense cells, the equivalent cells in the adult are a larger, lighter density population. The effects of injections of unrelated antigens on the physical properties of the AFC-progenitors in neonatal spleen were investigated to test the postulate that the physically distinct "virgin" AFC-progenitors in the adult arose by a process of non-specific activation. Spleen cells from 7-day-old germ-free CBA mice were separated by sedimentation at unit gravity or by density on continuous albumin gradients, and the fractions were tested for NIP-specific AFC-progenitor activity using an adoptive immune assay which gave a direct linear measure of B cell activity. If the donor neonatal animals were injected one day previously with POL or PPD, the NIP-specific AFC-progenitor activity shifted from the typical small, dense lymphocytes to larger, lighter cells. The physical properties of these stimulated AFC-progenitors resembled those of IgM AFC-progenitors in normal adult mice. These results experimentally confirm the theory that environmental stimuli induce a non-specific "activation" of a particular subset of "virgin" B cells.

Distribution of surface IgM and IgD on single cells from lymphocyte subpopulations.

The surface immunoglobulin heavy chains on individual spleen cells fractionated by velocity sedimentation were studied using fluorescent antisera. In adult mice, cells bearing both mu and delta chains were found in all fractions. While there was an increase in the proportion of cells bearing mu only in the medium to large cell fractions, the majority of cells bearing mu only were small lymphocytes. Results obtained using 3-week-old mice were basically similar, but showed both a marked decrease in small mu + delta + cells and a marked increase in small mu + delta - cells when compared with adult animals.

Surface immunoglobulin characteristics of B-lymphocyte developmental states and B-lymphocyte colony-forming cells.

B-lymphocyte colony-forming cells and various B-lymphocyte developmental states were examined for expression of surface immunoglobulin. B-lymphocyte colony-forming-cells appeared to possess a significantly greater amount of surface immunoglobulin than did newborn 'virgin' B lymphocytes. In terms of surface immunoglobulin content and physical property characteristics (established previously) B-lymphocyte colony-forming cells resembled a more mature B-lymphocyte subset. This subset, as characterized in previous studies, consists of mature virgin B cells that develop from the newborn virgin B cells via a process of nonspecific antigen-induced differentiation. An alternative possibility that B-lymphocyte colony-forming cells are memory B lymphocytes has not been eliminated by this study.

Monoclonal antibodies to murine CD40 define two distinct functional epitopes.

Two rat IgG2a antibodies which define distinct epitopes on murine CD40 have been generated. These antibodies specifically bind recombinant murine CD40 expressed on L cells, and the soluble extracellular domain of murine CD40 coated onto microtiter plates. Both antibodies bind B220+ but not B220 murine spleen cells, and immunoprecipitate a 45-kDa protein from the surface of purified murine splenic B cells. These antibodies exhibit separate functional properties, consistent with the notion that they define two distinct CD40 epitopes. One of the monoclonal antibodies (designated 1C10) directly induces a specific proliferative response from mature murine B cells, up-regulates several B cell surface antigens, and rescues immature B lymphoma cells from anti-IgM-induced growth arrest. The other monoclonal antibody (designated 4F11) exhibits none of these properties, but is capable of synergizing with suboptimal amounts of either anti-IgM antibodies or the 1C10 agonistic anti-CD40 antibody to produce an optimal proliferative response of purified small dense B cells. Furthermore, 4F11 antibody synergizes with suboptimal amounts of 1C10 antibody to rescue B lymphoma cells from anti-IgM-induced growth arrest. The 1C10 and 4F11 antibodies were unable to cross-block each other's binding to recombinant CD40 expressed in L cells, providing strong support for the notion that the antibodies recognize distinct epitopes on CD40. The potential implications of two functionally distinct CD40 epitopes are discussed.

Antigen-initiated B lymphocyte differentiation. XIV. Nonspecific effects of antigen stimulation cause proliferation in the "pre-progenitor" subset of primary B cells.

The effect of specific and nonspecific stimuli on the cycle status of subsets of primary B lymphocytes was assessed by preinjecting donor CBA mice 1 to 2 days previously with various substances, and then incubating the isolated spleen cells with high specific activity 3H-TdR before assay. AFC-progenitor activity was assessed as a response to NIP-POL antigen, either by adoptive transfer to irradiated recipients or by cell culture. Previous studies showed these assays reflected the activity of different subsets of B cells, termed "pre-progenitors" (adoptive assay) and "direct progenitors" (culture assay). Most functional primary B cells, whether assayed in culture or by adoptive transfer, were not initially in rapid cell cycle in normal adult mice. However, nonspecific stimulation for 1 day caused NIP-specific adoptive transfer IgM AFC-progenitors to enter rapid cell cycle. This effect was independent of T cells and not related to the antigenicity of the stimulus: particulate peritoneal irritants were the most effective stimulants. In contrast to adoptive transfer results. AFC-progenitors assayed in cell culture were unaffected by nonspecific stimuli, but were activated into cell cycle by specific antigen.

B lymphocyte subpopulations separated by velocity sedimentation. II. Characterization of tolerance susceptibility.

Neonatal and adult splenic B lymphocyte subpopulations, separated by velocity sedimentation, were tested in an in vitro splenic focus assay for their susceptibility to tolerance induction with hapten-protein conjugates. At least two tolerizable B cell subsets have been defined in the neonatal spleen; one comprising the slowly sedimenting, small lymphocytes and the other comprising the very rapidly sedimenting, large lymphocytes. In addition, a rapidly sedimenting large B cell subset in the adult spleen was found to be highly susceptible to tolerance induction. It was suggested that the inability to detect this susceptibility in unfractionated adult spleen was due to the low proportion of these very large lymphocytes in the total spleen cell population. The tolerizable B cell subsets presently defined probably represent the least mature B lymphocytes detectable in the splenic focus assay.

IL-13 protects mice from lipopolysaccharide-induced lethal endotoxemia: correlation with down-modulation of TNF-alpha, IFN-gamma, and IL-12 production.

IL-13 is a potent down-modulator of macrophage proinflammatory activity in vitro, similar in this context to the anti-inflammatory cytokines IL-4 and IL-10. Since IL-10 effectively confers protection to mice from LPS-induced lethal endotoxemia through inhibition of proinflammatory cytokine production, we investigated whether IL-13 may also be capable of providing protection in this experimental model of endotoxic shock. A single injection of recombinant murine IL-13 (rmIL-13; 0.5-10 microg) significantly increased survival in a dose-dependent manner when a lethal i.p. injection of endotoxin was administered to BALB/c mice. This effect appeared to be IL-13 specific, since survival was not affected in mice that received heat-inactivated rmIL-13. rmIL-13 provided significant protection to mice even when given 30 min after LPS injection; however, this protection decreased in a time-dependent manner as the administration of rmIL-13 was delayed by 1, 2, and 5 h following LPS injection. The protective effect of IL-13 was correlated with significant decreases in the production of the inflammatory mediators TNF-alpha, IFN-gamma, and IL-12 as well as a decrease in the anti-inflammatory mediator IL-10. Our data suggest that IL-13 provides protection from LPS-induced lethal endotoxemia in a manner that is similar to but independent from that of IL-10, and therefore can be added to the list of cytokine immunomodulators that might be beneficial in the treatment of septic shock.

Regulation of B lymphocyte development and activation by the CD19/CD21/CD81/Leu 13 complex requires the cytoplasmic domain of CD19.

B lymphocyte development and function are regulated in part by the CD19 cell surface receptor complex, which is composed of at least four proteins; CD19, CD21 (CR2, complement receptor 2), CD81, and Leu 13. Because this complex has eight membrane-spanning domains and six cytoplasmic regions, determining the molecular basis for its function and signal transduction activities has not been straightforward. In this study, the contribution of the CD19 cytoplasmic domain to the in vivo function of the CD19/CD21/CD81/Leu 13 complex was assessed by generating CD19-deficient mice that expressed a transgene that encoded only the extracellular and transmembrane domains of CD19. Mice expressing this transgene were similar, if not identical, to CD19-deficient mice with abnormal B cell development, a lack of B-1 cells, increased surface IgM levels on B cells, modest mitogen responses, minimal serum Ig levels, and low humoral immune responses. The results of this study indicate that specific signals generated through the cytoplasmic domain of CD19 are essential for B lymphocyte development and function, and that CD19 is the dominant signaling component of the CD19 complex. Moreover, expression of the CD19 cytoplasmic domain is required for optimal signaling through the B cell Ag receptor complex.

Rapid identification of antigenic T-cell epitopes by extracellular acidification rate signals.

We used a silicon-based biosensor, a microphysiometer, to measure real-time extracellular acidification rate signals associated with T lymphocyte responses to peptide ligands interacting with the T-cell receptor (TCR). We compared these effector responses with those of interferon-gamma (IFN-gamma) production, and T-cell proliferation. Within minutes, major histocompatibility complex (MHC)-bound peptides on antigen-presenting cells (APCs) engaged the TCR to increase acidification rates of the extracellular media was measured by microphysiometer. We exposed two myelin peptide-specific human T-cell clones, MSF132E11 (DRB1*1501 restricted) and TOM3A6 (DRB5*0101 restricted), to truncated analogues of the parent MBP 84-102 peptide, in the presence of MHC restricted human antigen-presenting cells, and measured the extracellular acidification rate signal changes, IFN-gamma production and T-cell proliferation. The core epitopes recognized by these clones were identified by microphysiometer and found to be MBP 88-100 and MBP 91-100, respectively. These epitopes were identical to those identified by the IFN-gamma and proliferation assays. We conclude that measurement of real-time extracellular acidification rate signals by the microphysiometer may facilitate rapid identification of human T-cell epitopes involved in immune disorders and the development of specific T-cell antagonists.

Expression of murine CD38 defines a population of long-term reconstituting hematopoietic stem cells.

Using a monoclonal antibody to murine CD38, we showed that a population of adult bone marrow cells that expressed the markers Sca-1 and c-kit but lacked the lineage markers Mac-1, GR-1, B220, IgM, CD3, CD4, CD8 and CD5 could be subdivided by the expression of CD38. We showed that CD38high c-kit+ Sca-1+, linlow/-cells sorted from adult bone marrow cultured with interleukin-3 (IL-3), IL-6, and kit-L produced much larger colonies in liquid culture at a greater frequency than their CD38low/- counterparts. In addition, we found that CD36low/ - cells contained most of the day-12 colony-forming units-spleen (CFU-S) but were not long-term reconstituting cells, whereas the population that expressed higher levels of CD38 contained few, but significant, day-12 CFU-S and virtually all the long-term reconstituting stem cells. Interestingly, the CD38high Sca-1+ c-kit+ linlow/- cells isolated from day-E14.5 fetal liver were also found to be long-term reconstituting stem cells. This is in striking contrast to human hematopoietic progenitors in which the most primitive hematopoietic cells from fetal tissues lack the expression of CD38. Furthermore, because antibodies to CD38 could functionally replace antibodies to Thy-1.1 in a stem cell purification procedure, the use of anti-CD38 may be more generally applicable to the purification of hematopoietic stem cells from mouse strains that do not express the Thy-1.1 allele.

Signaling through CD38 augments B cell antigen receptor (BCR) responses and is dependent on BCR expression.

mAbs directed against the ectoenzyme CD38 will induce B cell proliferation in normal resting B lymphocytes, but cannot induce proliferation in B cells that are unresponsive to B cell Ag receptor (BCR) cross-linking. Using the CD38- murine B cell line A20 we have examined the relationship between CD38- and BCR-mediated signaling after transfection of wild-type or mutant CD38 molecules. Although association between CD38 and the BCR was not detectable, co-cross-linking of CD38 and the BCR gave rise to a synergistic response, and expression of CD38 lowered the threshold for BCR-induced responses. Generation of Ig loss variant clones established that coexpression of the BCR was required for CD38-mediated signal transduction. The cytoplasmic tail of Ig alpha or Ig beta rescued CD 38 responsiveness in the CD38+Ig- cells provided that the chimeric molecules were coligated with CD38. Separate experiments indicated that the cytoplasmic tail of CD38 is not required for CD38 signaling. The anti-CD38-induced response was dependent on the influx of extracellular calcium but was not accompanied by detectable tyrosine phosphorylation of any cellular proteins. Together, these data demonstrate that the CD38 molecule can influence BCR-induced responses and that CD38 signaling is dependent on the BCR complex, perhaps to utilize a functional cytoplasmic tail(s) for intracellular signaling.

Hybridoma antibody immunoassays for the detection of parasitic infection: development of a model system using a larval cestode infection in mice.

A prototype immunodiagnostic assay has been developed using chronic infection with the larval cestode, Mesocestoides corti, as a model system in mice. The assay is highly sensitive, it appears to be absolutely specific for M. corti infection, and is based on the inhibition of binding (by sera from infected mice) of a radiolabelled anti-M. corti hybridoma antibody to a crude M. corti antigen extract. The hybridoma antibody binds to living M. corti larvae and is an IgG1 protein. In large scale experiments no false positives were detected and the only M. corti-infected mice not detected by the assay were hypothymic nude (nu/nu) mice. Only limited success has been achieved in attempts to convert the assay to one not requiring parasite antigen and based on the inhibition of binding of radiolabelled anti-parasite hybridoma antibody and a large pool of anti-idiotype antiserum. Monoclonal antibodies derived from anti-parasite antibody-secreting hybridoma cell lines will be of particular use in the development of new, highly specific, immunodiagnostic reagents for the detection of parasite infection, exposure and disease.

Protective effects of IL-4 and IL-10 against immune complex-induced lung injury.

Recombinant murine IL-4 and IL-10 have been used in two models of inflammatory lung injury in rats after intrapulmonary deposition of IgG or IgA immune complexes. These models have contrasting requirements for cytokines, phagocytic cells, and adhesion molecules. In these two models of lung injury, IL-4 and IL-10 were individually coinstilled into the airways with the IgG or IgA antibodies, whereas the Ag were injected intravenously. Injury was quantitated by increases in permeability (leakage of 125I-BSA) and by hemorrhage (extravasation of 51Cr-RBC). In the model of IgG immune complex-induced lung injury, IL-4 and IL-10 were each highly protective when given in nanogram amounts. These protective effects were dose dependent. IL-4 and IL-10 caused substantial reductions in lung content of myeloperoxidase and parallel reductions in neutrophil content in bronchoalveolar lavage (BAL) fluids. The protective effects of IL-4 and IL-10 were associated with profound reductions of TNF-alpha in the BAL fluids and complete inhibition in the up-regulation of pulmonary vascular ICAM-1. In the IgA immune complex model of lung injury IL-4 had no protective effects, whereas IL-10 was highly protective. These protective effects correlated with diminished retrieval of alveolar macrophages in BAL fluids. These data suggest that IL-4 and IL-10 have significant protective effects in lung inflammatory injury, presumably achieving these effects by various mechanisms.

The induction of a protective response in Leishmania major-infected BALB/c mice with anti-CD40 mAb.

A protective immune response to the intracellular parasite Leishmania major requires the development of a Th1 CD4+ T cell phenotype. We demonstrate herein that BALB/c mice, which normally develop a susceptible Th2 response to L. major infection, are protected when co-injected with an agonistic anti-murine CD40 mAb. Anti-CD40 mAb-mediated protection in this system was found to be T cell dependent, since it was not observed in C57BL/6 x 129 mice that were rendered T cell deficient (TCR beta-/- x TCR delta-/-) and L. major susceptible. Anti-CD40 mAb stimulation of L. major-infected BALB/c mice was accompanied by increased IL-12 and IFN-gamma production in draining lymph nodes, analyzed either by direct expression, or in an antigen-specific in vitro recall assay. The protective role of these cytokines was indicated by the finding that anti-CD40 mAb-mediated protection of L. major-infected BALB/c mice could be reversed by co-treating the animals with neutralizing anti-IL-12 and/or anti-IFN-gamma mAb. Collectively, these data suggest that BALB/c mice develop a protective Th1 CD4+ T cell response to L. major infection when co-injected with anti-CD40 mAb. While the CD40-CD40L interaction has been previously shown to be vital in the control of murine Leishmaniasis, the current study establishes in vivo that anti-CD40 mAb treatment alone is sufficient to protect BALB/c mice from L. major infection and raises the possibility of utilizing this approach for vaccination strategies.