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Background Vitamin D deficiency is underdiagnosed and undertreated, especially among people living with HIV (PLWH). Recently, there has been an increased interest in the role of vitamin D in cardiovascular disease (CVD). While vitamin D deficiency has been associated with CVD in observational studies in the general population, there are limited data in PLWH. We therefore performed an analysis to assess the relationship of vitamin D and coronary atherosclerosis using coronary CT angiography (CCTA).Methods Women living with HIV (WLWH) without known CVD were included. Based on the median value of serum vitamin D levels, participants were dichotomized to either the <25 ng/ml (lower vitamin D group) or =25 ng/ml (higher vitamin D group). CCTA was used to assess plaque characteristics.Results Forty-three WLWH were included in the analyses (mean age 46 ±8 years, 56% African American, duration of HIV 15 ±6 years, 83% undetectable HIV viral load). WLWH in the lower vitamin D group (n=22) had significantly higher numbers of segments with any coronary plaque (2.27 ±3.01 versus 0.38 ±0.97; P=0.02) and segments with non-calcified coronary plaque (1.41 ±1.82 versus 0.29 ±0.64; P=0.03) compared with WLWH in the higher vitamin D group (n=21). After adjusting for Framingham CHD risk point score, body mass index, diabetes and race, the relationship remained significant.Conclusions Our study demonstrates a significant, independent relationship between lower vitamin D status and higher numbers of noncalcified coronary plaque segments in WLWH. Further studies are warranted to evaluate the effect of vitamin D on CVD in PLWH. Trial Registration Identifier: NCT00455793.

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Epidemiologic data link psychological stress to adiposity. The underlying mechanisms remain uncertain.

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Background Mechanisms underlying the heightened myocardial infarction risk among HIV-infected women (versus non-HIV-infected women) remain unclear. Our objectives were to assess epicardial adipose tissue (EAT) volume and its associations among asymptomatic women with and without HIV.Methods A total of 55 HIV-infected and 27 non-HIV-infected women without known cardiovascular disease who underwent cardiac CT and metabolic/immune phenotyping were included. EAT volume derived from CT was compared among women with and without HIV, and within-group EAT associations were assessed. Next, immune and atherosclerotic plaque parameters were compared among groups stratified by HIV serostatus and high/low EAT (defined in reference to median EAT for each serostatus group).Results Asymptomatic HIV-infected women and age-matched non-HIV-infected women with comparable mean body mass index (28 ±1 versus 29 ±1 kg/m2) had similar median (IQR) volumes of EAT (54 [41–79] versus 65 [41–78] cm3; P>0.05); however, different within-group associations were noted. Markers of monocyte activation/arterial inflammation differed by HIV serostatus/EAT volume subgroup (CXCL10 [P=0.02], sCD163 [P=0.004], sCD14 [P=0.03], Lp-PLA2[P=0.04]; Pfor overall ANOVA) and were highest among HIV-infected women with excess EAT (versus HIV-infected women without excess EAT, non-HIV-infected women with excess EAT and non-HIV-infected women without excess EAT). The percentage of segments with non-calcified coronary plaque also differed by HIV serostatus/EAT volume subgroup and was highest among HIV-infected women with excess EAT.Conclusions Asymptomatic women with and without HIV have similar volumes of EAT, but drivers of EAT may differ between groups. HIV-infected women with excess EAT have highest-level immune activation and the highest percentage of non-calcified plaque. Future studies are needed to determine whether EAT contributes pathogenetically to HIV-associated cardiovascular disease in women.

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Results from several studies have suggested that people with HIV have an increased risk of cardiovascular disease, especially coronary heart disease, compared with people not infected with HIV. People living with HIV have an increased prevalence of traditional cardiovascular disease risk factors, and HIV-specific mechanisms such as immune activation. Although older, more metabolically harmful antiretroviral regimens probably contributed to the risk of cardiovascular disease, new data suggest that early and continuous use of modern regimens, which might have fewer metabolic effects, minimises the risk of myocardial infarction by maintaining viral suppression and decreasing immune activation. Even with antiretroviral therapy, however, immune activation persists in people with HIV and could contribute to accelerated atherosclerosis, especially of coronary lesions that are susceptible to rupture. Therefore, treatments that safely reduce inflammation in people with HIV could provide additional cardiovascular protection alongside treatment of both traditional and non-traditional risk factors.

Cardiovascular disease is one of the leading causes of morbidity and mortality in people living with HIV. Several epidemiological studies have shown an increased risk of myocardial infarction and stroke compared to uninfected controls. Although traditional risk factors contribute to this increased risk of cardiovascular disease, HIV-specific mechanisms likely also play a role. Systemic inflammation has been linked to cardiovascular disease in several populations suffering from chronic inflammation, including people living with HIV. Although antiretroviral therapy reduces immune activation, levels of inflammatory markers remain elevated compared to uninfected controls. The causes of this sustained immune response are likely multifactorial and incompletely understood. In this review, we summarize the evidence describing the relationship between inflammation and cardiovascular disease and discuss potential anti-inflammatory treatment options for cardiometabolic disease in people living with HIV.

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The purpose of a leading pedestrian interval (LPI) is to provide pedestrians with the opportunity to begin crossing the street before adjacent through-movement vehicles are permitted to proceed. This procedure allows pedestrians to establish a presence in the crosswalk; this presence increases the visibility of pedestrians to drivers and therefore reduces conflicts with turning vehicles. The City of Toronto, Ontario, Canada, implemented and formally evaluated an LPI in 2005. LPIs have been added to a few more intersections since then; however, the process has not been streamlined. For LPIs to be implemented at additional locations, an implementation guide and operating standard was needed. In answer to this need, transportation services of the City of Toronto developed an implementation and assessment guideline. The purpose of the guideline is to help traffic engineers identify suitable locations for LPIs by means of a checklist, determine the appropriate length of time for the LPI with a formula, and consider operation features that would maximize the positive safety effects and minimize any negative impact on vehicular capacity. The guideline also suggests a method for measuring improvements in intersection safety as a result of LPIs. Besides introducing various components of the newly developed guide, this paper provides a review of past studies on the effectiveness of LPIs in improving pedestrian safety and a review of the state of practice in other jurisdictions in regard to implementation and operation of LPIs.

Context:Little is known about renin-angiotensin-aldosterone system (RAAS) activation in relationship to visceral adipose tissue (VAT) accumulation in HIV-infected patients, a population at significant risk for insulin resistance and other metabolic disease.Design:Twenty HIV and 10 non-HIV-infected subjects consumed a standardized low sodium or liberal sodium diet to stimulate or suppress the RAAS, respectively. RAAS parameters were evaluated in response to each diet and a graded angiotensin II infusion. Further analyses were performed after groups were substratified by median VAT measured by magnetic resonance imaging.Results:Aldosterone concentrations during the low-sodium diet were higher in HIV than non-HIV-infected subjects [13.8 (9.7, 30.9) vs 9.2 (7.6, 13.6) ng/dL, P= .03] and increased across groups stratified by visceral adipose tissue (VAT) [8.5 (7.1, 12.8), 9.2 (8.1, 21.5), 11.4 (9.4, 13.8), and 27.2 (13.0, 36.9) ng/dL in non-HIV-infected without increased VAT, non-HIV-infected with increased VAT, HIV-infected without increased VAT, HIV-infected with increased VAT, respectively, overall trend P= .02]. Under this condition, plasma renin activity [3.50 (2.58, 4.65) vs 1.45 (0.58, 2.33) ng/mL · h, P= .002] was higher among the HIV-infected subjects with vs without increased VAT. Differences in the suppressibility of plasma renin activity by graded angiotensin infusion were seen stratifying by VAT among the HIV-infected group (P< .02 at each dose). In addition, aldosterone (P= .007) was an independent predictor of insulin resistance in multivariate modeling, controlling for VAT and adiponectin.Conclusion:These data suggest excess RAAS activation in relationship to visceral adiposity in HIV-infected patients that may independently contribute to insulin resistance. Mineralocorticoid blockade may have therapeutic potential to reduce metabolic complications in HIV-infected patients with increased visceral adiposity.

Some intestinal microbiota-generated metabolites of phosphatidylcholine are recognized to be proatherogenic. As the HIV population is vulnerable to cardiovascular disease and can develop intestinal dysbiosis associated with systemic inflammation, we investigated the novel relationship between microbiota-derived metabolites of phosphatidylcholine and coronary atherosclerosis in HIV.

HIV-infected patients have a high risk of myocardial infarction. We aimed to assess the ability of statin treatment to reduce arterial inflammation and achieve regression of coronary atherosclerosis in this population.

The purpose of a leading pedestrian interval (LPI) is to provide pedestrians with the opportunity to begin crossing the street before adjacent through-movement vehicles are permitted to proceed. This procedure allows pedestrians to establish a presence in the crosswalk; this presence increases the visibility of pedestrians to drivers and therefore reduces conflicts with turning vehicles. The City of Toronto, Ontario, Canada, implemented and formally evaluated an LPI in 2005. LPIs have been added to a few more intersections since then; however, the process has not been streamlined. For LPIs to be implemented at additional locations, an implementation guide and operating standard was needed. In answer to this need, transportation services of the City of Toronto developed an implementation and assessment guideline. The purpose of the guideline is to help traffic engineers identify suitable locations for LPIs by means of a checklist, determine the appropriate length of time for the LPI with a formula, and consider operation features that would maximize the positive safety effects and minimize any negative impact on vehicular capacity. The guideline also suggests a method for measuring improvements in intersection safety as a result of LPIs. Besides introducing various components of the newly developed guide, this paper provides a review of past studies on the effectiveness of LPIs in improving pedestrian safety and a review of the state of practice in other jurisdictions in regard to implementation and operation of LPIs.

Background HIV is associated with atherosclerosis and low high-density lipoprotein (HDL). With inflammation, HDL becomes dysfunctional. We previously showed that proinflammatory HDL has high HDL redox activity (HRA). In this study, we compare HRA in HIV-infected versus non-HIV-infected subjects and relate HRA to indices of macrophage activation and cardiovascular disease risk.Methods 102 HIV-infected subjects and 41 matched non-HIV controls without clinical cardiovascular disease underwent coronary CT angiography (CTA) and testing for immune/inflammatory biomarkers. The effect of purified HDL from each study subject on the oxidation rate of dihydrorhodamine-123 (DOR) was normalized to the DOR of pooled HDL from healthy subjects. The normalized ratio DOR subject/DOR pooled was used as a measure of HRA, with higher HRA suggesting dysfunctional HDL.Results HRA was higher in HIV-infected versus non-HIV subjects (1.4 ±0.01 versus 1.3 ±0.01, P=0.03). In multivariate modelling for HRA among all subjects, HIV status remained positively related to HRA (P=0.02), even after controlling for traditional cardiovascular risk factors, comorbid conditions and immune activation. Among HIV-infected subjects, HRA correlated inversely with HDL (rho=-0.32, P=0.002) and log adiponectin (r=-0.28, P=0.006), and correlated positively with log sCD163 (r=0.24, P=0.02) – a monocyte/macrophage activation marker – and with the percentage of non-calcified coronary atherosclerotic plaque (r=0.29, P=0.03). sCD163 remained significantly associated with HRA in multivariate modelling among HIV-infected subjects (P=0.03).Conclusions These data demonstrate increased HRA among HIV-infected subjects versus matched non-HIV subjects with comparable HDL levels. In HIV-infected subjects, HRA relates to macrophage activation and to non-calcified coronary atherosclerotic plaque, which may be rupture-prone. Further studies are needed in HIV-infected patients to elucidate the interplay between immune activation, HDL function and CVD risk. Clinical trial registration number: NCT 00455793.

The 2013 American College of CardiologyAmerican Heart Association (ACCAHA) cholesterol guidelines are being applied to HIV-infected patients but have not been validated in this at-risk population, which is known to have a high prevalence of subclinical high-risk morphology (HRM) coronary atherosclerotic plaque.

BackgroundHIV-infected patients are at increased risk of coronary artery disease (CAD). We evaluated the cost-effectiveness of cardiac screening for HIV-positive men at intermediate or greater CAD risk.DesignWe developed a lifetime microsimulation model of CAD incidence and progression in HIV-infected men.MethodsInput parameters were derived from two HIV cohort studies and the literature. We compared no CAD screening with stress testing and coronary computed tomography angiography (CCTA)-based strategies. Patients with test results indicating 3-vessel/left main CAD underwent invasive coronary angiography (ICA) and received coronary artery bypass graft surgery. In the stress testing + medication and CCTA + medication strategies, patients with 1–2-vessel CAD results received lifetime medical treatment without further diagnostics whereas in the stress testing + intervention and CCTA + intervention strategies, patients with these results underwent ICA and received percutaneous coronary intervention.ResultsCompared to no screening, the stress testing + medication, stress testing + intervention, CCTA + medication, and CCTA + intervention strategies resulted in 14, 11, 19, and 14 quality-adjusted life days per patient and incremental cost-effectiveness ratios of 49,261, 57,817, 34,887 and 56,518 Euros per quality-adjusted life year (QALY), respectively. Screening only at higher CAD risk thresholds was more cost-effective. Repeated screening was clinically beneficial compared to one-time screening, but only stress testing + medication every 5 years remained cost-effective. At a willingness-to-pay threshold of 83,000 €/QALY (∼100,000 US$/QALY), implementing any CAD screening was cost-effective with a probability of 75–95%.ConclusionsScreening HIV-positive men for CAD would be clinically beneficial and comes at a cost-effectiveness ratio comparable to other accepted interventions in HIV care.

Among HIV-infected patients, high rates of myocardial infarction (MI) and sudden cardiac death have been observed. Exploring potential underlying mechanisms, we used multidetector spiral coronary computed tomography angiography (coronary CTA) to compare atherosclerotic plaque morphology in HIV-infected patients and non-HIV-infected controls.

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Growth hormone therapy is commonly used in girls with Turner syndrome to improve short stature associated with the disease. Concerns have been raised, however, regarding the effect of growth hormone on glucose metabolism. In this Practice Point commentary, I discuss the findings of a cross-sectional study performed by Wooten et al. that evaluated growth hormone treatment in girls with Turner syndrome. The authors found that girls with Turner syndrome who received growth hormone treatment had a lower BMI, less intra-abdominal fat, less subcutaneous abdominal fat, and less total body fat than girls with Turner syndrome who never received growth hormone. Importantly, girls who were treated with growth hormone were less likely to have impaired glucose tolerance than girls who never received growth hormone. Although the results of this study are supportive of the long-term benefits of growth hormone treatment in girls with Turner syndrome, interpretation of these findings should also take into account the limitation that this study was not randomized.

Carotid intima-media thickness (IMT), measured ultrasonically, is a marker of subclinical atherosclerosis and thereby predicts future myocardial infarction and stroke. The investigators quantified IMT in the common carotid artery in 100 predominantly healthy women 24 to 59 years of age who were not known to have cardiovascular disease. The investigators predicted that IMT values were related to obesity because of findings that childhood obesity is associated with higher carotid IMT in the adult years. Carotid IMT also was related to levels of adiponectin and to depot-specific fat content (abdominal visceral and subcutaneous abdominal fat areas). Fat distribution was determined by computed tomography scanning and common carotid IMD by high-resolution B-mode ultrasonographic imaging.

Reports on the effect of making `Powder Blue Chevy,' on Janet Lo, a Toronto, Canada-based Chinese actress. Profile; Confusion between family values and the environment in Ontario; Attraction to the theater; Understanding of native Chinese customs; Theater showing of `Powder Blue Chevy;' Contact information; Ticket prices.