Changes in Sexual Behavior Over the COVID-19 Pandemic Among a Community-Based Cohort of Men Who Have Sex With Men in Columbus, Ohio

BACKGROUND

The purpose was to assess COVID-19 beliefs and attitudes and examine COVID-19-related changes in sexual behavior of men who have sex with men during 3 time periods: April-July 2020 (T1), August-December 2020 (T2), January-May 2021 (T3).

METHODS

Data were analyzed from 157 men who have sex with men in Ohio recruited to participate in a longitudinal multisite network study of syphilis epidemiology in 3 US cities: Columbus, Ohio; Baltimore, Maryland; and Chicago, Illinois. In April 2020, a COVID-19 module was appended to existing baseline and follow-up surveys to assess beliefs, attitudes, and changes in sexual behavior. Sample characteristics were summarized. Correlations between demographic variables (age, racial identity) and COVID-19 outcomes were examined.

RESULTS

In response to COVID-19 social distancing restrictions and self-reported anxiety, some men limited sexual activity at T1, but the majority (n = 105 [67%]) continued to engage in sex. The number of men engaging in sex increased over time (T2: n = 124 [79%]; T3: n = 121 [77%]). At T1, men not in a relationship more frequently reported having less sex compared with prepandemic (n = 39 [57%]). By T3, men in a relationship more frequently reported less sex (n = 32 [54%]). Increased anxiety about sex and condom use was positively correlated with identifying as a man of color (P < 0.001). Most of the sample reported either starting or increasing online sexual activity during each time period.

CONCLUSIONS

Future efforts to target sexual health during a pandemic or other health emergencies should prioritize men of color and address the unique perspective of both single and partnered men.

Food insecurity and adverse pregnancy outcomes among rural Malawian women

OBJECTIVE

To investigate whether food insecurity is associated with adverse pregnancy outcomes such as miscarriage, stillbirth, and neonatal mortality among women in rural Malawi.

METHODS

We analyzed data from the baseline (July 2014 to February 2015) and follow-up (January 2018 to May 2018) waves of a longitudinal study of reproductive-age women in rural Malawi. We sampled women from villages from the catchment area of a community hospital in rural Lilongwe district of Malawi using stratified cluster sampling. We classified women as food secure or insecure at baseline. Using unadjusted and adjusted log-binomial models, we used baseline data to examine the cross-sectional association between food insecurity and ever experiencing an adverse pregnancy outcome. We used baseline and follow-up data to assess the longitudinal association between food insecurity and experiencing a new adverse pregnancy outcome during follow-up. In a subgroup analysis, we repeated the longitudinal analysis after restricting the sample to women who had no adverse pregnancy outcomes at baseline.

RESULTS

We observed no significant cross-sectional association between baseline food insecurity and ever experiencing an adverse pregnancy outcome (adjusted prevalence ratio: 1.09; 95% confidence interval [CI]: 0.78-1.53). Baseline food insecurity was not associated with experiencing a new adverse pregnancy outcome during follow-up (adjusted risk ratio [aRR]: 1.14, 95% CI: 0.60-2.20) or in the subgroup analysis (aRR: 1.52, 95% CI: 0.78-2.96).

CONCLUSIONS

While food insecurity is a critical issue, in this cohort of rural Malawian women, food insecurity was not associated with adverse pregnancy outcomes.

The effect of training order on neuromuscular, endocrine and mood response to small-sided games and resistance training sessions over a 24-h period

OBJECTIVES

This study examined the acute effect of small-sided-game (SSG) and resistance training sequence on neuromuscular, endocrine and mood response over a 24-h (h) period.

DESIGN

Repeated measures.

METHODS

Fourteen semi-professional soccer players performed SSG-training (4vs4+goalkeepers; 6×7-min, 2-min inter-set recovery) followed by resistance training 2h later (back-squat, Romanian deadlift, barbell-hip-thrust; 4×4 repetitions, 4-min inter-set recovery; 85% 1 rep-max) (SSG+RES), and on a separate week reversed the session order (RES+SSG). Physical demands of SSG's were monitored using global positioning systems (GPS) and ratings of perceived exertion (RPE). Countermovement-jump (CMJ; peak power output; jump height) and brief assessment of mood were collected before (pre), during (0h) and after (+24h) both protocols. Salivary testosterone and cortisol concentrations were obtained at the same time-points but with the inclusion of a measure immediately prior to the second training session (+2h).

RESULTS

GPS outputs and RPE were similar between SSG-training during both protocols. Between-protocol comparisons revealed no significant differences at +24h in CMJ performance, mood, and endocrine markers. Testosterone was higher at 0h during RES+SSG in comparison to SSG+RES (moderate-effect; +21.4±26.7pgml^-1; p=0.010), yet was similar between protocols by +2h.

CONCLUSIONS

The order of SSG and resistance training does not appear to influence the physical demands of SSG's with sufficient recovery between two sessions performed on the same day. Session order did not influence neuromuscular, endocrine or mood responses at +24h, however a favourable testosterone response from the resistance first session may enhance neuromuscular performance in the second session of the day.

197. Infective Endocarditis Over a Five-Year Period in an Academic Teaching Center: The Validity of ICD Codes vs. Manual Chart Review

Background

Opioid dependence and overdose are at epidemic levels in the United States. Ohio has the third highest rate of opioid-related overdose deaths. Infectious complications of intravenous drug use (IDU) include increased acquisition of hepatitis C, HIV and infective endocarditis. In this study, we aimed to characterize cases of infective endocarditis admitted to our healthcare system over a five-year period. We additionally sought to determine the validity of using ICD codes to identify infective endocarditis cases and IDU.

Methods

Patients with ICD-9 or 10 discharge diagnosis codes for infective endocarditis were identified from our institution’s electronic health record. ICD codes pertaining to substance abuse were used to classify patients according to IDU status. Readmissions during the same episode of infective endocarditis were excluded. We compared chart review to ICD code for the identification of infective endocarditis and IDU in a random sample of 296 of 1590 cases.

Results

Of 296 charts reviewed, 133 (44.9%) were excluded because they did not meet criteria for definite infective endocarditis by modified Duke’s criteria or because the episode was a readmission. A total of 163 (55.1%) cases met inclusion criteria, all of whom were seen in consultation by the inpatient Infectious Disease service. Of these, 52 (31.9%) had ICD 9 or 10 codes linked to substance abuse. Following manual chart review, we established that in fact 86 of these 163 cases (52.8%) had evidence of substance abuse.

Conclusion

Misclassification due to use of ICD codes is a well-established challenge to epidemiological research. However, the extent of misclassification in this analysis was greater than expected. If prior research on IDU and infective endocarditis has relied on medical record data alone without verification through manual chart review, the observed epidemiological trends may not be accurate.

Disclosures

All authors: No reported disclosures.

420. Prevalence of Oropharyngeal Meningococcal Carriage in an Urban STD Clinic

Background

Neisseria meningitidis (Nm) can cause invasive disease, but it also asymptomatically colonizes the pharynx in approximately 10% of the general population. Older studies have reported higher carriage rates (>30%) among individuals attending sexually transmitted disease (STD) clinics. This study examined the prevalence of oropharyngeal Nm carriage in STD clinic attendees in Columbus, Ohio.

Methods

Per normal procedures, all patients presenting for care in the STD clinic who report oral sex in the last year are screened for oropharyngeal Neisseria gonorrhoeae (Ng) using nucleic acid amplification testing (NAAT). For the same patients, we also initiate cultures using media selective for Neisseria spp. Analytical Profile Index Neisseria-Haemophilus (API NH) and Nm-specific PCR screening is performed on colonies with oxidase-positive Gram-negative diplococci to distinguish between Ng and Nm. For this study, we then performed PCR-based genogrouping on confirmed Nm isolates.

Results

Between July 2018 and March 2019, oropharyngeal screening occurred at 5,015 patient visits and oropharyngeal Nm was detected at 163 visits (3.3%). Nm-positive individuals were primarily male (69.9%), Caucasian (62.6%), with non-Hispanic ethnicity (98.8%). The median age was 27 years and 5.5% were HIV-positive. Among male cases, 49.1% reported sex with men; among women, 98.0% reported sex with men. Meningococcal vaccination status was unknown for 71.2%, but 26.4% had documentation of prior MenACWY vaccination and 2.3% had prior MenB vaccination. Among the 163 cases, genogroup distribution was 23.9% B, 10.4% E, 9.8% Z, 3.1% C, 0.0% W, 0.0% Y, and 39.3% capsule null locus. For 13.5%, the selected screening approach could not determine genogroup.

Conclusion

In STD clinic patients reporting recent oral sex, we found a much lower prevalence of oropharyngeal Nm carriage compared with what has been reported historically for similar populations. While NmB was the most common capsular type identified by genogrouping, almost 40% of Nm isolates contained the capsule null locus, making them unable to express capsule. Additional studies should evaluate the effect of Nm vaccination programs on carriage among STD-clinic attendees.

Disclosures

All authors: No reported disclosures.

The neuromuscular, endocrine and mood responses to a single versus double training session day in soccer players

OBJECTIVES

This study profiled the 24h neuromuscular, endocrine and mood responses to a single versus a double training day in soccer players.

DESIGN

Repeated measures.

METHODS

Twelve semi-professional soccer players performed small-sided-games (SSG's; 4 vs 4+goalkeepers; 6×7-min, 2-min inter-set recovery) with neuromuscular (peak-power output, PPO; jump height, JH), endocrine (salivary testosterone, cortisol), and mood measures collected before (pre) and after (0h, +24h). The following week, the same SSG protocol was performed with an additional lower body strength training session (back-squat, Romanian deadlift, barbell hip thrust; 4×4 repetitions, 4-min inter-set recovery; 85% 1 rep-max) added at 2h after the SSG's.

RESULTS

Between-trial comparisons revealed possible to likely small impairments in PPO (2.5±2.2Wkg^-1; 90% Confidence Limits: ±2.2Wkg^-1), JH (-1.3; ±2.0cm) and mood (4.6; ±6.1AU) in response to the double versus single sessions at +24h. Likely to very likely small favourable responses occurred following the single session for testosterone (-15.2; ±6.1pgml^-1), cortisol (0.072; ±0.034ugdl^-1) and testosterone/cortisol ratio (-96.6; ±36.7AU) at +24h compared to the double session trial.

CONCLUSIONS

These data highlight that performance of two training sessions within a day resulted in possible to very likely small impairments of neuromuscular performance, mood score and endocrine markers at +24h relative to a single training session day. A strategy of alternating high intensity explosive training days containing multiple sessions with days emphasising submaximal technical/tactical activities may be beneficial for those responsible for the design and delivery of soccer training programs.

Sexual Behavior Latent Classes Among Men Who Have Sex With Men: Associations With Sexually Transmitted Infections

Men who have sex with men (MSM) are at disproportionate risk of acquisition of sexually transmitted infections (STIs). We used latent class analysis (LCA) to examine patterns of sexual behavior among MSM and how those patterns are related to STIs. We examined patterns of sexual behavior using behavioral and clinical data from a cross-sectional study of 235 MSM who presented to an urban sexual health clinic for STI testing. Analyzed data were collected using a combination of interviewer- and self-administered surveys and electronic health records. We used LCA to identify underlying subgroups of men based on their sexual behavior, described the demographics of the latent classes, and examined the association between the latent classes and STI status. We identified three latent classes of sexual behavior: Unprotected Anal Intercourse (UAI) Only (67%), Partner Seekers (14%), and Multiple Behaviors (19%). Men in the Multiple Behaviors class had a 67% probability of being STI positive, followed by men in the UAI Only class (27%) and men in the Partner Seekers class (22%). Examining the intersection of a variety of sexual practices indicates particular subgroups of MSM have the highest probability of being STI positive.

Assessing the Acceptability, Feasibility, and Effectiveness of a Tablet-Based Cervical Cancer Educational Intervention

Cervical cancer is a common and deadly disease, especially in developing countries. We developed and implemented an interactive, tablet-based educational intervention to improve cervical cancer knowledge among women in rural Malawi. Chichewa-speaking adult women in six rural villages participated. Each woman took a pretest, participated in the lesson, and then took a posttest. The lesson included information on cervical cancer symptoms, causes, risk factors, prevention, and treatment. Over the 6-month study period, 243 women participated. Women ranged in age from 18 to 77 years. Only 15 % had education beyond primary school. Nearly half of participants (48 %) had heard of cervical cancer prior to viewing the lesson. For these women, the median number of correct responses on the pretest was 11 out of 20; after the lesson, they had a median of 18 correct responses (p < 0.001). After the intervention, 93 % of women indicated a desire for cervical cancer screening. Despite lack of familiarity with computers (96 %), most women (94 %) found the tablet easy to use. A tablet-based educational program was an effective, feasible, and acceptable strategy to disseminate cervical cancer information to women with low education in rural Malawi. This method may be appropriate to distribute health information about other health topics in low-resource settings.

Serum vitamin D status and bacterial vaginosis prevalence and incidence in Zimbabwean women

BACKGROUND

Bacterial vaginosis, a highly prevalent vaginal condition, is correlated with many adverse reproductive outcomes. In some studies, low vitamin D status (measured as serum 25-hydroxyvitamin D, 25[OH]D) has been associated with increased prevalence of bacterial vaginosis.

OBJECTIVES

We examined the cross-sectional association between vitamin D status and prevalence of bacterial vaginosis, separately for pregnant and nonpregnant women. Using prospectively collected data, we also characterized the effect of time-varying vitamin D status on incident bacterial vaginosis.

STUDY DESIGN

We quantified 25(OH)D in stored sera collected quarterly from 571 Zimbabwean women participating in the Hormonal Contraception and Risk of HIV Acquisition Study. The analysis was restricted to women not using hormonal contraception. We characterized associations between vitamin D insufficiency (defined as 25[OH]D ≤ 30 ng/mL vs > 30 ng/mL) and prevalence of bacterial vaginosis among nonpregnant women at the enrollment visit and among pregnant women at the first follow-up visit that pregnancy was detected. Among women who were negative for bacterial vaginosis at enrollment (n = 380), we also assessed the effect of time-varying vitamin D status on incident bacterial vaginosis. We used the Liaison 25(OH)D total assay to measure 25(OH)D. Bacterial vaginosis was diagnosed via Nugent score.

RESULTS

At enrollment, the prevalence of bacterial vaginosis was 31% and overall median 25(OH)D was 29.80 ng/mL (interquartile range, 24.70-34.30 ng/mL): 29.75 ng/mL (interquartile range, 25.15-33.95 ng/mL) among women with bacterial vaginosis, and 29.90 ng/mL (interquartile range, 24.70-34.50 ng/mL) among women without bacterial vaginosis. Among pregnant women, the prevalence of bacterial vaginosis was 27% and overall median 25(OH)D was 29.90 ng/mL (interquartile range, 24.10-34.00 ng/mL): 30.80 ng/mL (interquartile range, 26.10-36.90 ng/mL) among women with bacterial vaginosis, and 29.10 ng/mL (interquartile range, 23.80-33.45 ng/mL) among women without bacterial vaginosis. Vitamin D levels ≤ 30 ng/mL were not associated with a prevalence of bacterial vaginosis in nonpregnant women (adjusted prevalence ratio, 1.04; 95% confidence interval, 0.81-1.34) or pregnant women (adjusted prevalence ratio, 0.88, 95% confidence interval, 0.51-1.54). Vitamin D levels ≤ 30 ng/mL were similarly not associated with incident bacterial vaginosis (adjusted hazard ratio, 0.98, 95% confidence interval, 0.73-1.31). Our findings were robust to alternative specifications of vitamin D status including using a cut point for vitamin D deficiency of < 20 ng/mL vs ≥ 20 ng/mL and modeling 25(OH)D as a continuous variable.

CONCLUSION

Among reproductive-age Zimbabwean women, insufficient vitamin D was not associated with increased bacterial vaginosis prevalence or incidence. Given established associations between bacterial vaginosis and poor reproductive outcomes, identification of factors leading to high bacterial vaginosis prevalence is urgently needed.

Condom use and sexually transmitted infections among Malagasy sex workers

We evaluated whether use of a short- or longer-term recall period for condom use was superior for assessing risk of acquisition of incident sexually transmitted infection (STI). Female sex workers ( n = 1000) in Madagascar took part in a randomized trial comparing counselling strategies for male and female condom promotion. We explored associations between women's self-reported condom use with clients and non-paying partners and incident STI, examining both short-term recall (last sex act) and longer-term recall (over the past month and year). Self-reported condom use was generally not associated with reduced STI risk, whether measured at the last act or over longer time periods; with clients or non-paying partners; and through unadjusted and adjusted modelling. No condom use measure (short versus longer time periods, with one or both partner types) was strongly predictive of STI, suggesting poor validity.

Pregnancy among sex workers participating in a condom intervention trial highlights the need for dual protection

BACKGROUND

Little is known about pregnancy rates among sex workers (SWs) or the factors that predispose SWs to this risk. We aimed to estimate the pregnancy incidence rate among Madagascar SWs participating in an intervention trial promoting use of male and female condoms and assess the influence of various predictive factors on pregnancy risk.

METHODS

SWs from two study clinics in Madagascar participated in a randomized trial to assess the effect of peer education and clinic-based counseling on use of male and female condoms and prevalence of sexually transmitted infections (STIs). Women were seen every 2 months for up to 18 months; they received structured interviews at every visit, and physical exams at baseline and every 6 months thereafter. Site staff recorded information on pregnancies during interviews; pregnancy data were then merged with trial data for this analysis.

RESULTS

Of 935 SWs in the analysis population, 250 became pregnant during follow-up. The cumulative probability of pregnancy was 0.149 at 6 months and 0.227 at 12 months. Comparable proportions of nonpregnant and pregnant SWs reported using highly effective contraception at baseline (approximately 16%); these users were younger and were more consistent condom users. Method switching and discontinuation were frequent. In multivariate analysis, nonuse of effective contraceptives and any self-reported unprotected sex were associated with higher incidence of pregnancy. Approximately 51% of women delivered, 13% reported a spontaneous abortion, 13% reported an induced abortion and 23% had missing pregnancy outcomes.

CONCLUSIONS

Women traditionally targeted for STI/HIV preventive interventions need more comprehensive reproductive health services. In particular, SWs could benefit from targeted family planning counseling and services.

Diagnosis and treatment of presumed STIs at Mexican pharmacies: survey results from a random sample of Mexico City pharmacy attendants

OBJECTIVES

People in developing countries often seek medical advice for common ailments from pharmacies. As one example, pharmacists routinely diagnose and treat symptomatic sexually transmitted infections (STIs). We aimed to assess the quality of advice provided in Mexico City pharmacies by presenting hypothetical STI related syndromes and recording pharmacy attendants' suggested diagnoses and treatments.

METHODS

We interviewed the first available attendant in each of a 5% random sample of Mexico City's pharmacies. We inquired about the training, age, and experience of the attendant and about the typical number of clients coming for treatment of suspected STIs. After considering three hypothetical case studies, attendants recommended diagnoses, treatments, and, sometimes, physician follow up.

RESULTS

Most Mexico City "pharmacists" are actually clerks, with trained pharmacists rarely available on the premises. The average pharmacy attendant was 32 years old, with a median of 5 years' experience at that pharmacy, but very limited (if any) training. 62% reported seeing 10 or more clients with genital or vaginal infections per month. Depending on the case study, attendants provided appropriate diagnoses in 0-12% of cases, recommended appropriate treatments in 12-16% of cases, and suggested physician follow up for 26-67% of cases.

CONCLUSIONS

In general, surveyed pharmacy personnel were unable to diagnose accurately or offer appropriate treatment advice when presented with classic, common STI symptoms. Given the volume of clients seeking advice from this source, training pharmacy attendants could significantly help to reduce the burden of disease associated with STIs in Mexico City.

The Goodpasture antigen is expressed in the human thymus

BACKGROUND

Autoimmunity to kidney antigens causes membranous nephropathy and Goodpasture's disease and very likely is pivotal in many other glomerular diseases. We investigated the potential for central tolerance to the best-characterized kidney autoantigen, the NC1 domain of the alpha3 chain of type IV collagen [alpha3(IV)NC1], which is the target of autoimmune attack in Goodpasture's disease.

METHODS

Indirect immunofluorescence on human thymus and polymerase chain reaction (PCR) and Southern blot analysis of cDNA reverse transcribed from RNA extracted from human thymus and kidney.

RESULTS

Indirect immunofluorescence on human thymus demonstrated the presence of alpha3(IV)NC1 in all six thymus samples examined. The homologous collagen IV chain, alpha5(IV)NC1, also was detected with a similar intra-thymic distribution. Strikingly, thymic alpha3 and alpha5 localized around and within Hassall's corpuscles in the thymic medulla, which are structures implicated in T cell apoptosis and possibly negative selection. In contrast, alpha1(IV)NC1 localized to the basement membranes of interlobular septa and blood vessels, as is typical of collagen IV chains situated outside the thymus. Reverse transcription-polymerase chain reaction (RT-PCR) confirmed the presence of mRNA encoding alpha3(IV)NC1 and alpha5(IV)NC1 in thymic tissue establishing that the antigens were likely to have been synthesized locally.

CONCLUSIONS

The results demonstrate that alpha3(IV)NC1 is expressed in the human thymus, and therefore should be available for induction of alpha3(IV)NC1-specific tolerance. This observation has the important implication that patients' alpha3(IV)NC1-specific, autoreactive T cells are more likely to recognize cryptic epitopes that are not adequately presented by thymic antigen-presenting cells (APC) than the major antigen-derived epitopes generally identified by conventional approaches.

Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression

BACKGROUND

Anti-glomerular basement membrane (GBM) antibody disease is an autoantibody-mediated disorder that usually presents as rapidly progressive glomerulonephritis, often with pulmonary hemorrhage (the Goodpasture syndrome). It is reported that patients with severe renal failure do not generally recover renal function.

OBJECTIVE

To examine the long-term outcome of severe anti-GBM antibody disease.

DESIGN

Retrospective review of patients treated for confirmed anti-GBM antibody disease over 25 years.

SETTING

A tertiary referral center in the United Kingdom.

PATIENTS

71 treated patients with anti-GBM antibody disease.

INTERVENTION

All patients received plasma exchange, prednisolone, and cyclophosphamide.

MEASUREMENTS

Patient and renal survival, renal histology, and antibody levels.

RESULTS

Patients who presented with a creatinine concentration less than 500 micromol/L (5.7 mg/dL) (n = 19) had 100% patient survival and 95% renal survival at 1 year and 84% patient survival and 74% renal survival at last follow-up. In patients who presented with a creatinine concentration of 500 micromol/L or more (>/=5.7 mg/dL) (n = 13) but did not require immediate dialysis, patient and renal survival were 83% and 82% at 1 year and 62% and 69% at last follow-up. In patients who presented with dialysis-dependent renal failure (n = 39), patient and renal survival were 65% and 8% at 1 year and 36% and 5% at last follow-up. All patients who required immediate dialysis and had 100% crescents on renal biopsy remained dialysis dependent.

CONCLUSIONS

Patients with the Goodpasture syndrome and severe renal failure should be considered for urgent immunosuppression therapy, including plasma exchange, to maximize the chance of renal recovery. Patients needing immediate dialysis are less likely to recover.

Identification of an interactive effect of beta3- and alpha2b-adrenoceptor gene polymorphisms on fat mass in Caucasian women

Several adrenoceptor subtypes are expressed in adipocytes, which together exert their influence on adipocyte metabolism. Therefore, we specifically examined the interactive effect of Trp64Arg (beta3) and Glu12/Glu9 (alpha2b) adrenoceptor (AR) polymorphisms on energy metabolism and body composition in healthy women with a wide range of body habitus. We genotyped 909 unrelated women (age 55 +/- 12 [mean +/- SD] years, range 19-87; body weight 88 +/- 22 kg, range 40-167; and BMI 33 +/- 8 kg/m2, range 16-64) for Trp64Arg beta3AR and Glu12/Glu9 alpha2bAR variants. We examined the independent effect of the Glu12/Glu9 alpha2bAR variant on body composition and energy balance, in a large cohort of Caucasian women (n = 909). A second goal was to examine the interaction effect of Glu12/Glu9 alpha2bAR and Trp64Arg beta3AR on the same phenotypes. The obesity-related phenotypes studied were as follows: body weight, BMI, fat mass, visceral fat, fat-free mass, resting metabolic rate (RMR), VO2max, leisure time physical activity, and daily energy intake. Body composition and body fat distribution were measured by dual-energy X-ray absorptiometry and radiographic imagery, VO2max by a treadmill test to exhaustion, and RMR by indirect calorimetry. An analysis of covariance indicated that in the entire cohort, there was no significant difference between Glu12/Glu9 alpha2bAR carriers and control subjects for any of the obesity-related phenotypes that were examined. However, we observed a significant interaction effect of the Trp64Arg and Glu12/Glu9 variants on fat mass (P = 0.009) and percent fat (P = 0.016). Age, height, body weight, BMI, fat-free mass, visceral fat, energy expenditure, respiratory quotient, physical fitness, and energy intake were not different among groups. Collectively, these findings support an interaction effect of the two adrenoceptor variants on body fatness in Caucasian women, although the physiological mechanism by which they exert this effect remains to be determined.

Properties of HLA class II molecules divergently associated with Goodpasture's disease

Goodpasture's disease provides an opportunity to analyse molecular mechanisms that may underlie MHC class II associations with autoimmune disease because it is caused by autoimmunity to a defined antigen [the 230 amino acid NC1 domain of the alpha3 chain of type IV collagen (alpha3(IV)NC1)] and has strong HLA class II associations. We compared the alpha3(IV)NC1 peptide binding of class II molecules with strong positive (DR15) and dominant negative (DR7/1) associations using an inhibition binding assay and short synthetic peptides spanning the sequence of alpha3(IV)NC1. DR15 in general bound the peptides with low affinity (three of 23 < 100 nM) compared to DR1 and DR7 (12 and 10 < 100 nM respectively), and no peptide bound DR15 with much higher affinity (>10-fold) than both DR1 and DR7. Thus DR15 molecules are unlikely to increase susceptibility to Goodpasture's disease by presenting a particular alpha3(IV)NC1-derived peptide uniquely well and DR1/7 are unlikely to protect by their inability to present particular peptides. However DR1/7 could protect by capturing alpha3(IV)NC1 peptides and preventing their display bound to DR15; the binding data suggest that all the major (biochemically detectable) alpha3(IV)NC1 peptides presented bound to DR15 by DR15 homozygous antigen-presenting cells (APC) would bind preferentially to DR1/7 in DR15, 1/7 heterozygote APC.

[Anti glomerular basement membrane disease in a renal transplant patient with Alport syndrome]

We report a case of anti GBM disease that developed in the renal graft of a patient with Alport syndrome. After reaching abnormal values of creatinine, the patient presented with deteriorating renal function three months after a cadaver transplant and the biopsy showed crescent formation, and linear IF deposits. Circulating antibodies against alpha 5 chain of type IV collagen were found and plasmaphereses stabilized the condition for one year until a lung infection led to withdrawal of the immunosuppressive drugs and the patient returned to dialysis. We discuss the possible mechanisms underlying the specificity of the circulating antibodies in this case, which differs from the target characteristic of the idiopathic form of anti GBM disease, the alpha 3 (IV) chain.

Presentation of the Goodpasture autoantigen to CD4 T cells is influenced more by processing constraints than by HLA class II peptide binding preferences

Class II molecules are believed to influence immune responses by selectively binding antigen-derived peptides for recognition by T cells. In Goodpasture's (anti-glomerular basement membrane) disease, autoimmunity to the NC1 domain of the alpha3-chain of type IV collagen (alpha3(IV)NC1) is strongly associated with HLA-DR15. We have examined the influence of the peptide binding preferences of DR15 molecules on the selection of alpha3(IV)NC1-derived peptides displayed bound to DR15 molecules on the surface of alpha3(IV)NC1-pulsed DR15-homozygous Epstein-Barr virus-transformed human B cells. The preferences of DR15 molecules were investigated using a panel of 24 overlapping peptides spanning the sequence of alpha3(IV)NC1. The alpha3(IV)NC1-derived peptides selected for display to T cells were determined by biochemical analysis as reported previously (Phelps, R. G., Turner, A. N., and Rees, A. J. (1996) J. Biol. Chem. 271, 18549-18553). Three nested sets of naturally presented alpha3(IV)NC1 peptides were detectable bound to DR15 molecules. Peptides representative of each nested set bound to DR15 molecules, but almost two-thirds of the alpha3(IV)NC1 peptides studied had as good or better DR15 affinity than those identified as naturally processed. Thus alpha3(IV)NC1 presentation to T cells is determined more by "processing factors" than by the preferences of relatively indiscriminate DR15 molecules. The results have important implications for the use of class II peptide binding data to aid identification of potential T cell epitopes, especially for antigens which, like alpha3(IV)NC1, contain many sequences able to bind class II molecules.

Sequence analysis of the 'Goodpasture antigen' of mammals

BACKGROUND

Autoimmunity to the NC1 domain of the alpha3 chain of type IV collagen (alpha3(IV)NC1), the Goodpasture antigen, is the cause of spontaneous human antiglomerular basement membrane (anti-GBM) disease, and of anti-GBM nephritis in several animal models.

METHODS

We have derived amino acid sequences from alpha3(IV)NC1 for a number of mammalian species (monkey, sheep, pig, dog, rabbit, and rat) by RT-PCR and cDNA cloning. The GBM of some species was studied comparatively for binding to Goodpasture autoantibodies.

RESULTS

From this work and other data the sequences of nine mammalian species can be aligned. Regions and residues that may be functionally important are identified. Alpha3(IV)NC1 sequences were found to be less closely conserved across species than alpha1 and alpha2(IV)NC1, 91 to 99% in comparison to a minimum of 97% for alpha1, but these differences were unevenly distributed along the molecule. There was a particularly striking homology between rodent and human sequences in the carboxyl-terminal region. Binding of Goodpasture autoantibodies to rat alpha3(IV)NC1 was poor in comparison with other species.

CONCLUSIONS

Comparison of sequences and binding casts doubt on the importance of the carboxyl-terminal region for antibody binding, a region identified as a potential major epitope in previous studies. Sequence comparisons suggest possible reasons for the nephritogenicity of alpha3(IV)NC1 in active models of anti-GBM disease.

Targets of alloantibodies in Alport anti-glomerular basement membrane disease after renal transplantation

A minority of patients with Alport syndrome develop anti-GBM disease in their allografts after renal transplantation. Clinically, the renal disease appears indistinguishable from Goodpasture's disease of native kidneys, in which the target of autoantibodies had been identified as the NC1 domain of the alpha 3 chain of type IV collagen, alpha 3(IV)NC1. However, in the majority of cases, Alport syndrome is due to mutations in the gene encoding the alpha 5 chain of type IV collagen, located on the X chromosome. Neither chain is detectable in the glomerular basement membrane (GBM) of most patients with Alport syndrome. We investigated the targets of the alloantibodies of 12 Alport patients who developed post-transplant anti-GBM disease by Western blotting onto recombinant NC1 domains made in insect cells. Binding to these antigens, for both typical Goodpasture and Alport anti-GBM antibodies, was strong and conformation-sensitive. Nine antibodies showed selective binding to alpha 5(IV)NC1. This specificity was confirmed by the demonstration of binding to a 26 kDa band of collagenase-solubilized human GBM, and/or binding to normal epidermal as well as renal basement membranes by indirect immunofluorescence. One antibody showed binding to alpha 5 and alpha 3(IV)NC1, while two showed predominant binding to alpha 3(IV)NC1. All seven patients whose pedigree or mutation analysis showed X-linked inheritance had predominant anti-alpha 5 reactivity. One with predominant anti-alpha 3 reactivity had a COL4A3 mutation. These findings show that human anti-GBM disease can be associated with antibodies directed towards different molecular targets. Alpha 5(IV)NC1 is the primary target in most patients with X-linked Alport syndrome who develop post-transplant anti-GBM disease.

Epitope analysis of the Goodpasture antigen using a resonant mirror biosensor

We have used a new technique for studying molecular interactions-a resonant mirror biosensor-to identify B cell epitopes within the Goodpasture antigen, which has recently been identified as the non-collagenous domain of the alpha 3-chain of type IV collagen (alpha 3(IV)NC1). Recombinant antigen (r-alpha 3) was immobilized onto the sensing surface of a sample cuvette, and the binding of patients' autoantibodies or a MoAb to the Goodpasture antigen was followed in real time. All patients' sera bound r-alpha 3 in this system, while control sera did not bind. A MoAb inhibited the binding of all patients' autoantibodies to r-alpha 3, from 27% to 90% (mean inhibition 60%), and patients' sera cross-inhibited the binding of each other to the antigen. Binding was inhibited by pre-incubation of autoantibody with both native sheep alpha 3(IV)NC1 and purified human alpha 3(IV)NC1 monomers. Inhibition experiments using soluble overlapping peptides from human alpha 3(IV)NC1 identified putative B cell epitopes. These results suggest that there is a major immunodominant epitope on the Goodpasture antigen, and that there is very limited heterogeneity in the autoantibody response in Goodpasture's disease. The resonant mirror biosensor can be successfully used to monitor antibody-antigen binding using polyclonal sera, and to map epitopes on autoantigens.

Direct identification of naturally processed autoantigen-derived peptides bound to HLA-DR15

Biochemical analysis of HLA class II-associated peptides from antigen-pulsed cells is a potentially useful approach to the analysis of antigen processing and presentation because it examines directly which antigen-derived peptides are presented. This is especially advantageous in the analysis of self-antigen presentation where conventional approaches utilizing antigen-specific T cells may be biased by the presence of self-tolerance. However, successful biochemical analysis has been reported for only one exogenous antigen and no autoantigens. We have used a novel analytical approach coupling biochemical data with the reported properties of class II-associated peptides to characterize the peptides derived from a clinically relevant autoantigen presented on the disease-associated class II type. Incubating the target of autoimmune attack in patients with Goodpasture's disease, the 230-amino acid NC1 domain of the alpha3 chain of type IV collagen (Goodpasture antigen, alpha3(IV)NC1), with human B cells homozygous for HLA-DR15, the allele carried by 80% of patients, we find that alpha3(IV)NC1 is presented as at least two sets of three to five peptides centered on common core sequences (nested sets). Synthetic peptides containing these core sequences bind to HLA-DR15 with intermediate affinity (IC50, 1.1-6 microM).

Goodpasture's disease and Alport's syndromes

Goodpasture's, or anti-glomerular basement membrane, disease is an uncommon, usually severe disease caused by autoimmunity to a component of certain basement membranes. Alport's syndrome is an inherited, degenerative disorder that affects specific basement membranes. The two are linked by the involvement of type-IV collagen (basement membrane collagen) in their pathogenesis.

Significance of autoantibodies to purified proteinase 3 in systemic vasculitis

Proteinase 3 was purified from human neutrophils and used in ELISA to examine sera from 150 patients with systemic vasculitis. It was found to be the major target of autoantibodies in Wegener's granulomatosis, and anti-proteinase 3 antibodies were also found in some patients with microscopic polyarteritis. Anti-proteinase 3 antibodies were associated with a chronic relapsing course.

Plasma exchange in refractory cutaneous vasculitis

Eight patients with intractable cutaneous leucocytoclastic vasculitis were given a trial of plasma-exchange therapy. All but one improved, five substantially. Four have been successfully treated by intermittent plasma exchange for periods of 5-12 years. Apart from one episode of hepatitis B, possibly related to administration of fresh frozen plasma, no major adverse effects have occurred. Plasma exchange can be a valuable therapeutic option in patients with severe refractory cutaneous vasculitis.

Prednisolone and chlorambucil treatment in idiopathic membranous nephropathy with deteriorating renal function

Eight patients with idiopathic membranous nephropathy whose renal function was deteriorating were given a 6-month course of alternating monthly cycles of prednisolone and chlorambucil. Proteinuria was reduced in all eight, from a mean (SD) of 15.3 (5.9) g/24 h at the start of treatment to 2.1 (1.5) g/24 h at follow-up (p less than 0.05). Creatinine clearance increased in six, and the rate of decline was reduced in the other two (group mean 51.6 [17.8] ml/min at the start of treatment and 81.4 [36.8] ml/min at follow-up; p less than 0.05). Adverse effects of chlorambucil were severe, and the daily dose had to be reduced. Prednisolone and chlorambucil treatment can change the natural course of membranous nephropathy even when renal function has started to deteriorate, so treatment can be reserved for high-risk patients.

Consulting is more than giving advice

Of all the relationships that executives enter into with outsiders, perhaps none is so tainted by misunderstanding as the engagement of management consultants. To executives, consultants may seem concerned mainly with prolonging their assignments and unable to appreciate the practicalities of managerial issues. Conversely, consultants may see their clients as short-sighted and lacking the backbone necessary to make important decisions. How can such stereotypes be done away with? By starting at the beginning of the assignment. Mr. Turner maintains that if managers and outside advisers work out in advance what is expected of each party during their work together, the chances of solving problems are improved. He suggests that managers and consultants structure the engagement according to a hierarchy of goals--which proceeds from the most basic objective, providing information, to the most sophisticated, permanent improvement of organizational effectiveness. The best way to move up that hierarchy is for executives and advisers to work together to identify needs and develop solutions.