International standards to document remaining autonomic function after spinal cord injury.

STUDY DESIGN: Experts opinions consensus. OBJECTIVE: To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI). BACKGROUND AND RATIONALE: The impact of a specific SCI on a person's neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a person's autonomic function. METHODS: Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function. RESULTS: Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function. CONCLUSION: This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.

Sexual health outcome measures for individuals with a spinal cord injury: a systematic review.

STUDY DESIGN: A systematic review of all sexual health outcome measures reporting psychometric properties for a spinal cord injury (SCI) population. OBJECTIVES: To evaluate the psychometric evidence for sexual health outcome measures used in a SCI population in order to (1) determine the clinical relevance of current tools and (2) suggest recommendations for future tool development. SETTING: Vancouver, British Columbia, Canada. METHODS: Electronic databases were searched for articles reporting psychometric properties of sexual health outcome measures used in a SCI population. The search was limited to papers published between January 1986 and January 2006. Hand-searching the references of papers obtained from the electronic search identified additional articles. RESULTS: Four outcome measures met the search criteria: Emotional Quality of the Relationship Scale (EQR), Sexual Activity and Satisfaction Scale (SAS), Sexual Attitude and Information Questionnaire (SAIQ) and Sexual Interest and Satisfaction Scale (SIS). While the clinical utility of these tools may be compromised by their limited scope and advancing age, they may still prove useful for guiding SCI research and clinical practice. CONCLUSION: There is no clinically agreed upon SCI measurement tool for sexual health outcomes. To adequately assess the complex issue of sexual health, it is recommended that future sexual health outcome measures include both quantitative and qualitative data as well as address several key issues.

Spinal cord injury influences psychogenic as well as physical components of female sexual ability.

STUDY DESIGN: Secure, web-based survey. OBJECTIVES: Elicit specific information about sexual function from women with spinal cord injuries (SCI). SETTING: World-wide web. METHODS: Individuals 18 years or older living with SCI obtained a pass code to enter a secure website and then answered survey questions. RESULTS: Bladder and/or bowel incontinence during sexual activity and/or sexual intercourse were significant concerns and prevented some women from seeking sexual activity. Autonomic dysreflexia (AD) during sexual activity was interpreted negatively by many and was found to interfere with sexual activity. Most subjects reported difficulty becoming psychologically aroused as well as physically aroused, which were both correlated with feeling that their SCI had altered their sexual sense of self. An inverse relationship existed between developing new areas of arousal above the level of lesion and not having sensation or movement below the lesion. The most commonly reported sexual stimulation leading to the best arousal involved stimulation of the head/neck and torso areas. The majority of subjects reported having experienced intercourse postinjury. Most participants reported difficulty with positioning during foreplay and intercourse, vaginal lubrication, and spasticity during intercourse. Almost half reported experiencing orgasm postinjury and this was positively associated with the presence of genital sensation. CONCLUSION: SCI significantly impairs psychological and physical aspects of female sexual arousal. In addition, bladder and bowel incontinence as well as AD negatively impact sexual activity and intercourse.

The impact of spinal cord injury on sexual function: concerns of the general population.

STUDY DESIGN: Secure, web-based survey. OBJECTIVES: Obtain information from the spinal cord injured (SCI) population regarding sexual dysfunctions, with the aim of developing new basic science and clinical research and eventual therapies targeting these issues. SETTING: Worldwide web. METHODS: Individuals 18 years or older living with SCI. Participants obtained a pass-code to enter a secure website and answered survey questions. A total of 286 subjects completed the survey. RESULTS: The majority of participants stated that their SCI altered their sexual sense of self and that improving their sexual function would improve their quality of life (QoL). The primary reason for pursuing sexual activity was for intimacy need, not fertility. Bladder and bowel concerns during sexual activity were not strong enough to deter the majority of the population from engaging in sexual activity. However, in the subset of individuals concerned about bladder and/or bowel incontinence during sexual activity, this was a highly significant issue. In addition, the occurrence of autonomic dysreflexia (AD) during typical bladder or bowel care was a significant variable predicting the occurrence and distress of AD during sexual activity. CONCLUSION: Sexual function and its resultant impact on QoL is a major issue to an overwhelming majority of people living with SCI. This certainly constitutes the need for expanding research in multiple aspects to develop future therapeutic interventions for sexual health and SCI.

Long-term effects of spinal cord injury on sexual function in men: implications for neuroplasticity.

STUDY DESIGN: Secure, web-based survey. OBJECTIVES: Elicit specific information about sexual function from men with spinal cord injuries (SCI). SETTING: World-wide web. METHODS: Individuals 18 years or older living with SCI obtained a pass-code to enter a secure website and then answered survey questions. RESULTS: The presence of genital sensation was positively correlated with the ability to feel a build up of sexual tension in the body during sexual stimulation and in the feeling that mental arousal translates to the genitals as physical sensation. There was an inverse relationship between developing new areas of arousal above the level of lesion and not having sensation or movement below the lesion. A positive relationship existed between the occurrence of spasticity during sexual activity and erectile ability. Roughly 60% of the subjects had tried some type of erection enhancing method. Only 48% had successfully achieved ejaculation postinjury and the most commonly used methods were hand stimulation, sexual intercourse, and vibrostimulation. The most commonly cited reasons for trying to ejaculate were for pleasure and for sexual intimacy. Less than half reported having experienced orgasm postinjury and this was influenced by the length of time postinjury and sacral sparing. CONCLUSION: SCI not only impairs male erectile function and ejaculatory ability, but also alters sexual arousal in a manner suggestive of neuroplasticity. More research needs to be pursued in a manner encompassing all aspects of sexual function.

Menstrual cycle-dependent changes of Toll-like receptors in endometrium.

BACKGROUND: Rapid innate immune defences against infection usually involve the recognition of invading pathogens by specific pattern recognition receptors recently attributed to the family of Toll-like receptors (TLRs). Reports from our laboratory and others have demonstrated the existence of TLRs 1-6 in the female reproductive tract. However, little has been done to identify TLRs 7-10 in the female reproductive tract, particularly in the uterus. Also little information exists regarding variation in TLRs in the female reproductive tract during the menstrual cycle. METHOD: The distribution of TLR7-10 protein was detected by immunostaining in timed endometrial biopsies from normal women. RT-PCR was used to show the existence of TLR1-10 genes in endometrial tissue and real-time PCR analysis to investigate the relative expression of these genes during the menstrual cycle in normal human endometrium. RESULTS: TLR7-10 proteins were detected in endometrial epithelium and stroma. TLR1-10 genes were expressed in human endometrial tissue, and the mean relative expression of TLR2-6, 9 and 10 genes was significantly higher during the secretory phase compared with other phases of the menstrual cycle. CONCLUSIONS: TLR7-10 localization is not limited to endometrial epithelium but is also present in the stroma of the endometrial tissue. Endometrial TLR2-6, 9 and 10 genes are cyclically expressed during the menstrual cycle.

Selecting the future doctors: the role of graduate medical programmes.

Graduate-entry medical programmes have been introduced in many Australian states. This has coincided with the introduction of learner-centred, problem-orientated medical courses and has resulted in a need to develop new selection pathways. Medical schools have complemented their primary selection tool of academic performance with tests of personal attributes considered important in future doctors. Schools with graduate-entry programmes now employ a combination of the results of the applicant's undergraduate degree, a semistructured interview and a psychometric test (the Graduate Australian Medical School Admissions Test) to select students. Rationale for the change to graduate entry and the outcomes of this change will be discussed.

Identification of biodegradation products formed by L-phenylalanine based segmented polyurethaneureas.

The degradation of novel biodegradable segmented polyurethanes was investigated with a view to determining the cleavage points within the polymer backbones targeted by the enzyme chymotrypsin. While the materials were developed with specific enzyme cleavage sites designed into the polymer chains, the nature of their degradation had not yet been determined. In this work, two segmented polyurethaneureas containing L-phenylalanine residues in the chain extender and two control polymers were subjected to degradation in the presence of chymotrypsin. Samples were collected for analysis over a time period from 1 day to 8 weeks. The degradation products from these materials were isolated using solid phase extraction and reversed phase high pressure liquid chromatography, and identified using mass and tandem mass spectrometry. Three hard segment related degradation products were identified and provide important insight into the polyurethane backbone cleavage sites. Cleavage of urea, ester and urethane bonds were observed. The results confirmed that chymotrypsin was able to cleave ester bonds adjacent to phenylalanine residues contained within the novel chain extender.

Asymptomatic primary Epstein-Barr virus infection occurs in the absence of blood T-cell repertoire perturbations despite high levels of systemic viral load.

Primary infection with the human herpesvirus, Epstein-Barr virus (EBV), may result in subclinical seroconversion or may appear as infectious mononucleosis (IM), a lymphoproliferative disease of variable severity. Why primary infection manifests differently between patients is unknown, and, given the difficulties in identifying donors undergoing silent seroconversion, little information has been reported. However, a longstanding assumption has been held that IM represents an exaggerated form of the virologic and immunologic events of asymptomatic infection. T-cell receptor (TCR) repertoires of a unique cohort of subclinically infected patients undergoing silent infection were studied, and the results highlight a fundamental difference between the 2 forms of infection. In contrast to the massive T-cell expansions mobilized during the acute symptomatic phase of IM, asymptomatic donors largely maintain homeostatic T-cell control and peripheral blood repertoire diversity. This disparity cannot simply be linked to severity or spread of the infection because high levels of EBV DNA were found in the blood from both types of acute infection. The results suggest that large expansions of T cells within the blood during IM may not always be associated with the control of primary EBV infection and that they may represent an overreaction that exacerbates disease.

Assessment in problem-based learning: the role of the tutor.

INTRODUCTION: Problem-based learning (PBL) in medicine emphasises the tutor's role in facilitating collaborative and integrated learning. While it is widely recognised that tutors come to know their students, they traditionally play little part in the formal assessment process. We introduced tutor assessment into a problem-based medical curriculum and examined the patterns of tutor marks in four subjects, in terms of within semester consistency and their relation to other forms of assessment in the course. MATERIALS AND METHOD: Seventy-four tutors assessed 187 students twice (formative assessment in mid-semester, summative assessment at the end of semester) in each semester, using an assessment tool that focussed on communication and learning skills. Tutor marks were examined using correlations, cluster analysis and chi-square coefficients. RESULTS: There were consistent trends in the patterns of cluster membership for pairs of marks in high, average and low clusters from mid-semester formative to end-of-semester summative assessment. Cluster membership for pairs of marks was predominantly consistent. Most movement was from lower to higher clusters over the two assessments, reflecting student improvement after tutors' feedback and tutor responsiveness to feedback to them. There was little variance in the marks of different tutors. Tutor marks correlated moderately and significantly with other forms of assessment in each subject. CONCLUSION: Tutor marks contribute useful, distinctive dimensions to assessment in a problem-based medical curriculum.

Rural training and the state of rural health services: effect of rural background on the perception and attitude of first-year medical students at the university of melbourne.

The aim of this project is to investigate the relationship between medical students' background and their perception of the state of rural health services; willingness to undertake internship training or work as a doctor in a rural hospital; expected benefits and disadvantages of training or working as a doctor in a rural hospital; and factors interfering with acceptance of a job as a doctor in rural areas. A questionnaire-based survey was distributed to 100 first-year medical students attending the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne at the end of semester 1. The response rate was 97%, including 44 males and 53 females. A strong relationship was found between rural background and an intention to undertake internship training in a rural hospital (86% of students from a rural background expressed this desire vs 30% of students from an urban background). Furthermore, all students from a rural background expressed a desire to work as a doctor in a rural hospital after completing postgraduate training. Compared to urban students, students from a rural background showed a more positive attitude towards health services in rural areas including public hospitals ( P = 0.02), private general practice ( P = 0.004), ambulance service ( P = 0.0002) and baby health centres ( P = 0.005). Citizenship or gender was not significantly related to the perception of any of these services. The ranking of factors interfering with acceptance of a job as a doctor in rural areas were different for rural and urban students. Students from rural backgrounds reported spouse/partner needs (76% vs 49%, P = 0.038) and school availability for children (59% vs 30%, P = 0.023) as barriers more frequently than urban students, respectively). On the other hand, urban students rated the following factors higher: personal factors (76% vs 53%, respectively), education opportunities (56% vs 24%), social/cultural facilities (50% vs 41%) and the need for frequent travel (29% vs 12%). None of these interfering factors were significantly different. Urban students were more likely than rural students to report that their views were a result of adverse media reports. In conclusion, students from a rural background were more willing to be trained or to work as doctors in rural areas. This was associated with a greater adverse influence by the media upon students.

Effect of pre-existing cytotoxic T lymphocytes on therapeutic vaccines.

Therapeutic vaccines which aim to induce CD8(+) cytotoxic T lymphocyte (CTL) responses will often be required to perform in the presence of pre-existing CTL which recognize epitopes within the vaccine. Here we explore the ability of a viral vaccine vector presenting several co-dominant CTL epitopes to prime CTL responses in animals that have a pre-existing CTL response to one of the epitopes in the vaccine. The vaccine was usually capable of inducing multiple new responses, suggesting that immunodomination effects of pre-existing CTL may generally be minimal following vaccination. However, when large numbers of pre-existing CTL were present, a novel type of immune modulation was observed whereby (1) the vaccine failed to prime efficiently new CTL responses that were restricted by the same MHC gene as the pre-existing responses, and (2) vaccine-induced CTL responses restricted by other MHC genes were enhanced. These results may have implications for therapeutic multi-epitope vaccines for diseases like HIV and melanoma, which aim to broaden CTL responses.

Activation and adoptive transfer of Epstein-Barr virus-specific cytotoxic T cells in solid organ transplant patients with posttransplant lymphoproliferative disease.

The treatment of Epstein-Barr virus (EBV)-associated lymphoproliferative disease (PTLD) in EBV seronegative solid organ transplant recipients who acquire their EBV infection after engraftment poses a considerable challenge because of underlying immunosuppression that inhibits the virus-specific cytotoxic T cell (CTL) response in vivo. We have developed a protocol for activating autologous EBV-specific CTL lines from these patients and show their potential use for immunotherapy against PTLD in solid organ transplant patients. Peripheral blood mononuclear cells from a panel of solid organ transplant recipients with and without active PTLD were used to assess EBV-specific memory CTL responses. The activation protocol involved cocultivation of peripheral blood mononuclear cells with an autologous lymphoblastoid cell line under conditions that favored expansion of virus-specific CTL and hindered the proliferation of allospecific T cells. These CTL consistently showed (i) strong EBV-specificity, including reactivity through defined epitopes in spite of concurrent immunosuppressive therapy, and (ii) no alloreactivity toward donor alloantigens. More importantly, adoptive transfer of these autologous CTLs into a single patient with active PTLD was coincident with a very significant regression of the PTLD. These results demonstrate that a potent EBV-specific memory response can be expanded from solid organ recipients who have acquired their primary EBV infection under high levels of immunosuppressive therapy and that these T cells may have therapeutic potential against PTLD.

An HLA-A2 polyepitope vaccine for melanoma immunotherapy.

Epitope-based vaccination strategies designed to induce tumor-specific CD8 CTL are being widely considered for cancer immunotherapy. Here we describe a recombinant poxvirus vaccine that codes for ten HLA-A2-restricted epitopes derived from five melanoma Ags conjoined in an artificial polyepitope or polytope construct. Target cells infected with the melanoma polytope vaccinia were recognized by three different epitope-specific CTL lines derived from HLA-A2 melanoma patients, and CTL responses to seven of the epitopes were generated in at least one of six HLA-A2-transgenic mice immunized with the construct. CTL lines derived from vaccinated transgenic mice were also able to kill melanoma cells in vitro. Multiple epitopes within the polytope construct were therefore shown to be individually immunogenic, illustrating the feasibility of the polytope approach for melanoma immunotherapy. Tumor escape from CTL surveillance, through down regulation of individual tumor Ags and MHC alleles, might be overcome by polytope vaccines, which simultaneously target multiple cancer Ags.

Developing immunotherapeutic strategies for the control of Epstein-Barr virus-associated malignancies.

Epstein-Barr virus (EBV) infection is associated with various physical human malignancies. The potential for immunotherapeutic treatment by cytotoxic T cells (CTL) depends on the degree of EBV-antigen expression, with the best prospect revolving around the immunoblastic lymphomas of organ transplant patients in which adoptive transfer of in vitro reactivated CTL has already been demonstrated to be effective. Opportunities for effective immunotherapy in the treatment of nasopharyngeal carcinoma (NPC) is reduced because the available targets are limited to relatively nonimmunogenic proteins. However, analysis of NPC cells has revealed normal expression of the major histocompatibility complex (MHC)-encoded peptide transporters TAP-1 and TAP-2, together with high levels of human leukocyte antigen (HLA) class I alleles on the cell surface. Burkitt's lymphoma (BL) displays downregulated expression of MHC class I and TAP-1 and TAP-2 proteins, whereas viral antigen expression is limited to a protein incapable of processing class I CTL epitopes. It therefore seems likely that effective treatment of BL will revolve around protocols designed to reverse its undifferentiated phenotype.

Immunogenicity of a human immunodeficiency virus (HIV) polytope vaccine containing multiple HLA A2 HIV CD8(+) cytotoxic T-cell epitopes.

Compelling evidence now suggests that alphabeta CD8 cytotoxic T lymphocytes (CTL) have an important role in preventing human immunodeficiency virus (HIV) infection and/or slowing progression to AIDS. Here, we describe an HIV type 1 CTL polyepitope, or polytope, vaccine comprising seven contiguous minimal HLA A2-restricted CD8 CTL epitopes conjoined in a single artificial construct. Epitope-specific CTL lines derived from HIV-infected individuals were able to recognize every epitope within the construct, and HLA A2-transgenic mice immunized with a recombinant virus vaccine coding for the HIV polytope also generated CTL specific for different epitopes. Each epitope in the polytope construct was therefore processed and presented, illustrating the feasibility of the polytope approach for HIV vaccine design. By simultaneously inducing CTL specific for different epitopes, an HIV polytope vaccine might generate activity against multiple challenge isolates and/or preempt the formation of CTL escape mutants.

Female preferences in a fish genus without female mate choice.

The evolution and the adaptive logic (if any) of female mate choice are subjects of lively debate. Whereas most researchers believe that females have evolved to recognize signs of male 'quality' (the ability to provide females or their offspring with direct or indirect genetic or material benefits), there is intriguing evidence that males can evolve to appeal to pre-existing female preferences. Evidence for these pre-existing biases is often ambiguous because phylogenetic reconstructions have usually failed to establish conclusively whether the female preference or the favored male traits evolved first. This potential difficulty is minimal in the mosquitofish genus Gambusia, none of whose 45 species appears to have a female-choice mating system in the wild, and none of which shows the male behavioral and morphological traits that are characteristic of female choice. Nevertheless, in an experimental situation in the laboratory, female Gambusia holbrooki readily chose between models of males and demonstrated significant and reliable preferences for a variety of exaggerated male traits that are not seen in their species or their genus. Other morphological alterations were not preferred. The latent willingness of females to choose traits in a genus without such traits and without evident female choice in the wild is remarkable and may indicate a pre-existing bias in females that is ready to drive male evolution, should the social system or the ecological variables that control it change.

Peptide based cytotoxic T-cell vaccines; delivery of multiple epitopes, help, memory and problems.

Synthetic CD8+ cytotoxic T-lymphocyte (CTL) peptide epitope based vaccines are being developed against a number of human diseases. Here we describe extensive preclinical testing of peptide epitope vaccines formulated with a protein as a source of CD4 help and Montanide ISA 720, an adjuvant currently in human clinical trials. Such water-in-oil formulations could effectively co-deliver several peptide epitopes and simultaneously induce multiple independent CTL responses. The efficiency of CTL induction by some peptides was, however, dependent on the aqueous buffer conditions, with poor performance correlating with non-covalent peptide oligomerisation. Any of a number of proteins currently used in human vaccines could supply CD4 help and no difference in CTL induction was obtained if the CD4 response was amnestic or a primary. Peptide immunisation was found to induce long term CTL memory and the recall of protective responses did not depend on an amnestic CD4 response. Slow pyroglutamic acid formation and rapid oxidation of methionine residues was observed in water-in-oil formulations, however, the latter had no effect on CTL induction. These data highlight the need to monitor for potential deleterious chemical events and interpeptide interactions, but illustrate that peptide based vaccination can effectively deliver multiple epitopes, in conjunction with any protein, and induce protective memory.

Crossreactive recognition of viral, self, and bacterial peptide ligands by human class I-restricted cytotoxic T lymphocyte clonotypes: implications for molecular mimicry in autoimmune disease.

The immunodominant, CD8(+) cytotoxic T lymphocyte (CTL) response to the HLA-B8-restricted peptide, RAKFKQLL, located in the Epstein-Barr virus immediate-early antigen, BZLF1, is characterized by a diverse T cell receptor (TCR) repertoire. Here, we show that this diversity can be partitioned on the basis of crossreactive cytotoxicity patterns involving the recognition of a self peptide-RSKFRQIV-located in a serine/threonine kinase and a bacterial peptide-RRKYKQII-located in Staphylococcus aureus replication initiation protein. Thus CTL clones that recognized the viral, self, and bacterial peptides expressed a highly restricted alphabeta TCR phenotype. The CTL clones that recognized viral and self peptides were more oligoclonal, whereas clones that strictly recognized the viral peptide displayed a diverse TCR profile. Interestingly, the self and bacterial peptides equally were substantially less effective than the cognate viral peptide in sensitizing target cell lysis, and also resulted only in a weak reactivation of memory CTLs in limiting dilution assays, whereas the cognate peptide was highly immunogenic. The described crossreactions show that human antiviral, CD8(+) CTL responses can be shaped by peptide ligands derived from autoantigens and environmental bacterial antigens, thereby providing a firm structural basis for molecular mimicry involving class I-restricted CTLs in the pathogenesis of autoimmune disease.