Factors influencing foot care behaviour among patients with diabetes: An integrative literature review.

AIM: The aim of the study was to examine factors influencing diabetic foot care behaviours (DFCBs) among patients with diabetes. DESIGN: An Integrative review using the Whittemore & Knafl five-stage framework. METHODS: A systematic search was performed to retrieve relevant peer-reviewed literature published in English between 2011 and 2021 across three electronic databases: CINAHL, Medline (PubMed) and Scopus. Following the quality appraisal, 35 papers were included in this review. RESULTS: This review revealed that patients' DFCBs were suboptimal. Additionally, four emerging themes were identified as the predictors of DFCB, namely: demographic characteristics as predictors of diabetic foot care behaviour; illness beliefs and perceptions as predictors of diabetic foot care behaviour; foot care knowledge as a predictor of diabetic foot care behaviour and foot care education as a predictor of diabetic foot care behaviour. This calls for nurses to devise educational strategies that adequately address these determinants to drive long-term positive DFCB among patients.

Moving away from mannitol infusion for partial nephrectomy: has this altered renal function?

In recent years, research has questioned the theorized renal-protective value of mannitol infusion during partial nephrectomy. This study considers whether the cessation of routine mannitol administration has shown any benefit or detriment to patients in the contemporary era. We retrospectively reviewed a multi-institution database for an association between mannitol administration and subsequent renal function during follow-up. These patients were assessed for de novo stage III chronic kidney disease (CKD III) and followed with estimated glomerular filtration rate (eGFR). Statistical analysis included Mann-Whitney-U and Chi-squared tests for comparing baseline and perioperative variables with postoperative outcomes. eGFR changes were evaluated with a mixed-effects linear regression model. Nine hundred and fifteen patients were identified whose operative reports or surgeons' treatment algorithms explicitly described whether or not mannitol was administered. 667 (73%) did not receive mannitol. There were no differences in demographics, age, Charlson comorbidity index, nephrometry score, tumor size, grading, or baseline eGFR from those who received mannitol. Ischemia time and operative time appeared slightly longer with mannitol use. Patients were followed for a median of 5 months (IQR 0.5-19 months), during which mannitol use was associated with an increase in de novo CKD III (14% v. 9%, p = 0.041) and minimally worsened median eGFR on final follow-up (72.82 v. 76.06, p = 0.039). Our analysis of partial nephrectomy patients indicates that mannitol administration likely confers no short- or long-term renal benefit. Mannitol may be used at the surgeon's discretion, but if it prolongs surgery time or ischemia time, it may in fact be detrimental to outcomes.

Program for Reducing Obesity (PRO): An institutional review of an insurance-based weight loss program utilizing shared medical appointments.

Background: Based on CDC estimates in the United States, the prevalence of obesity was 42.4% in 2017-2018, and the annual cost of obesity was $147 billion in 2008. Yet studies estimate that only 20-40% of adults with obesity received counseling from their primary care providers. Recent studies using shared medical appointments (SMA), where patients are seen by a multidisciplinary team, have shown promising results in obesity management. We developed an insurance-based weight loss program incorporating SMA, called the Program for Reducing Obesity (PRO), and report our findings here. Methods: Enrollment began in January 2019 at the UCLA Health Thousand Oaks clinic. Patients age ≥18 years with BMI ≥30 kg/m2 were eligible by referral to PRO, a program consisting of individual visits and SMAs with an obesity medicine board certified endocrinologist and registered dietitian. Primary outcomes were change in weight after 3, 6, and 12 months. Secondary outcomes included proportion that achieved ≥5% weight loss, change in percent body fat, HbA1c, HDL, triglycerides, and blood pressure. Results: 102 patients (mean age 59.7 years, 72% women, mean weight 103.6 kg, mean BMI 36.6 kg/m2) have been analyzed, with 91 patients completing at least 12 months of the program. Patients achieved significant weight loss: 3.0%, 5.0%, and 7.8% of their baseline weight after 3, 6, and 12 months respectively. 52% of patients lost ≥5% of their baseline weight after 12 months. Patients had significant reductions in body fat: 2.1%, 7.4%, and 6.7% of their baseline (all p ≤ 0.01) after 3, 6, and 12 months respectively. Improvements were also seen in HbA1c (p ≤ 0.01), triglycerides (p ≤ 0.04), and systolic blood pressure (p ≤ 0.07) after 12 months although not all results achieved statistical significance. Conclusion: Our institutional review of PRO, an insurance-based obesity program utilizing SMA, demonstrates a successful approach to promoting weight loss in a community-based setting.

Multiple brain metastases in a patient with ypT0N0 micropapillary urothelial carcinoma of the bladder.

Radical cystectomy (RC) after neoadjuvant chemotherapy (NAC) is the gold standard for management of muscle-invasive bladder cancer (MIBC). Patients without residual tumor at the time of extirpative surgery (ypT0) have excellent prognosis. Distant metastases in this population are rare. We present a unique case of a patient with ypT0N0 urothelial carcinoma (UC) with rapid development of metastasis to the brain.

Nurses' experiences in voluntary error reporting: An integrative literature review.

OBJECTIVE: This integrative review aimed to examine and understand nurses' experiences of voluntary error reporting (VER) and elucidate factors underlying their decision to engage in VER. METHOD: This is an integrative review based on Whittemore & Knafl five-stage framework. A systematic search guided by the PRISMA 2020 approach was performed on four electronic databases: CINAHL, Medline (PubMed), Scopus, and Embase. Peer-reviewed articles published in the English language from January 2010 to December 2020 were retrieved and screened for relevancy. RESULTS: Totally 31 papers were included in this review following the quality appraisal. A constant comparative approach was used to synthesize findings of eligible studies to report nurses' experiences of VER represented by three major themes: nurses' beliefs, behavior, and sentiments towards VER; nurses' perceived enabling factors of VER and nurses' perceived inhibiting factors of VER. Findings of this review revealed that nurses' experiences of VER were less than ideal. Firstly, these negative experiences were accounted for by the interplays of factors that influenced their attitudes, perceptions, emotions, and practices. Additionally, their negative experiences were underpinned by a spectrum of system, administrative and organizational factors that focuses on attributing the error to human failure characterized by an unsupportive, blaming, and punitive approach to error management. CONCLUSION: Findings of this review add to the body of knowledge to inform on the areas of focus to guide nursing management perspectives to strengthen institutional efforts to improve nurses' recognition, reception, and contribution towards VER. It is recommended that nursing leaders prioritize and invest in strategies to enhance existing institutional error management approaches to establish a just and open patient safety culture that would promote positivity in nurses' overall experiences towards VER.

Nursing students' views and satisfaction of their clinical learning environment in Singapore.

Aims: This study aims to investigate final-year nursing students' actual perception of their clinical learning environment in Singapore. Design: Descriptive cross-sectional survey. Methods: An online survey based on the clinical learning environment inventory (CLEI; "Actual" version) was administered to final-year (third year) nursing students (N = 301) in a polytechnic in Singapore between May-July 2018. Results: Most nursing students reported moderate satisfaction with their clinical learning environment, reflecting their positive (although not strongly positive) perceptions. Among the six constructs of the CLEI, the higher scores of the constructs of "Personalization" and "Task orientation" implied their greater contribution to the positive view. Conversely, the lower scores of "Individualization" and "Innovation" implied their lesser contribution. Additionally, the positive correlation between "satisfaction" and the other five CLEI constructs was found to be statistically significant.

The experience of transition from nursing students to newly graduated registered nurses in Singapore.

OBJECTIVES: To investigate the experience of newly graduated registered nurses (NGRNs) in Singapore following their initial 6-12 months of transition from nursing student to registered nurse. METHODS: This mixed-methods study consisted of two phases. In the first phase, data were collected via the administration of the online survey to 30 NGRNs. The questionnaire contained 42 items of the four-point Likert scale survey. In the second phase, a focus group interview was conducted with 5 NGRNs to gather complementary information regarding the major findings from the first phase. RESULTS: The survey revealed despite most NGRNs (80%) in this study expressed overall satisfied with their transition, the item score was (2.97±0.61) out of 4, the majority (83.3%) also perceived their transition to professional practice being stressful, the item score was (3.07±0.74) out of 4.Three themes emerged from the interview, 'personal transition experience', 'professional transition experience', and 'organizational transition experience', which are entwined to construct overall NGRNs' transition experiences. CONCLUSIONS: This study reaffirms the theory-practice gap phenomenon. This signifies the need for closer collaboration between educational, healthcare industry and regulatory stakeholders to examine and address factors that influence their transition experience to better support them for workforce readiness.

Effects of statin therapy on coronary artery plaque volume and high-risk plaque morphology in HIV-infected patients with subclinical atherosclerosis: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: 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. METHODS: In a randomised, double-blind, placebo-controlled trial, 40 HIV-infected participants with subclinical coronary atherosclerosis, evidence of arterial inflammation in the aorta by fluorodeoxyglucose (FDG)-PET, and LDL-cholesterol concentration of less than 3.37 mmol/L (130 mg/dL) were randomly assigned (1:1) to 1 year of treatment with atorvastatin or placebo. Randomisation was by the Massachusetts General Hospital (MGH) Clinical Research Pharmacy with a permuted-block algorithm, stratified by sex with a fixed block size of four. Study codes were available only to the MGH Research Pharmacy and not to study investigators or participants. The prespecified primary endpoint was arterial inflammation as assessed by FDG-PET of the aorta. Additional prespecified endpoints were non-calcified and calcified plaque measures and high risk plaque features assessed with coronary CT angiography and biochemical measures. Analysis was done by intention to treat with all available data and without imputation for missing data. The trial is registered with ClinicalTrials.gov, number NCT00965185. FINDINGS: The study was done from Nov 13, 2009, to Jan 13, 2014. 19 patients were assigned to atorvastatin and 21 to placebo. 37 (93%) of 40 participants completed the study, with equivalent discontinuation rates in both groups. Baseline characteristics were similar between groups. After 12 months, change in FDG-PET uptake of the most diseased segment of the aorta was not different between atorvastatin and placebo, but technically adequate results comparing longitudinal changes in identical regions could be assessed in only 21 patients (atorvastatin Δ -0.03, 95% CI -0.17 to 0.12, vs placebo Δ -0.06, -0.25 to 0.13; p=0.77). Change in plaque could be assessed in all 37 people completing the study. Atorvastatin reduced non-calcified coronary plaque volume relative to placebo: median change -19.4% (IQR -39.2 to 9.3) versus 20.4% (-7.1 to 94.4; p=0.009, n=37). The number of high-risk plaques was significantly reduced in the atorvastatin group compared with the placebo group: change in number of low attenuation plaques -0.2 (95% CI -0.6 to 0.2) versus 0.4 (0.0, 0.7; p=0.03; n=37); and change in number of positively remodelled plaques -0.2 (-0.4 to 0.1) versus 0.4 (-0.1 to 0.8; p=0.04; n=37). Direct LDL-cholesterol (-1.00 mmol/L, 95% CI -1.38 to 0.61 vs 0.30 mmol/L, 0.04 to 0.55, p<0.0001) and lipoprotein-associated phospholipase A2 (-52.2 ng/mL, 95% CI -70.4 to -34.0, vs -13.3 ng/mL, -32.8 to 6.2; p=0.005; n=37) decreased significantly with atorvastatin relative to placebo. Statin therapy was well tolerated, with a low incidence of clinical adverse events. INTERPRETATION: No significant effects of statin therapy on arterial inflammation of the aorta were seen as measured by FDG-PET. However, statin therapy reduced non-calcified plaque volume and high-risk coronary plaque features in HIV-infected patients. Further studies should assess whether reduction in high-risk coronary artery disease translates into effective prevention of cardiovascular events in this at-risk population. FUNDING: National Institutes of Health, Harvard Clinical and Translational Science Center, National Center for Research Resources.

Effects of lifestyle modification and metformin on irisin and FGF21 among HIV-infected subjects with the metabolic syndrome.

OBJECTIVE: Few studies have investigated irisin and FGF21 to elucidate the role of these hormones to regulate 'beiging' in HIV-infected patients. DESIGN: Fifty HIV-infected subjects with the metabolic syndrome were previously recruited and randomized to receive lifestyle modification (LSM) and/or metformin over 12 months. In the current study, we assessed FGF21 and irisin at baseline and after intervention. In addition, we assessed circulating FGF21 and irisin in relationship to brown adipose tissue (BAT) gene expression in dorsocervical subcutaneous fat biopsies from 13 HIV-infected subjects. RESULTS: At baseline, prior to intervention, HIV-infected subjects demonstrated increased log FGF21 (2·13 ± 0·06 vs 1·98 ± 0·05 pg/ml, P = 0·05) and log irisin (0·33 ± 0·02 vs 0·17 ± 0·04 µg/ml, P = 0·003) compared with healthy controls well matched based on waist circumference. After 12 months, HIV-infected subjects randomized to LSM demonstrated a relative reduction in FGF21 compared with those not randomized to LSM (-10 [-35,22] vs 40 [0,94] %change, P = 0·01). Changes in FGF21 were inversely associated with improved parameters of energy homoeostasis, including increased REE (ρ = -0·34, P = 0·046) and max VO2 (ρ = -0·38, P = 0·02), and reduced RQ (ρ = 0·40, P = 0·02) among all HIV-infected subjects. Increased UCP-1 (r = 0·75, P = 0·003), DIO2 (r = 0·58, P = 0·04) and CideA (r = 0·73, P = 0·01) gene expression in dorsocervical fat was significantly associated with FGF21 in HIV-infected subjects. CONCLUSION: HIV-infected subjects with metabolic complications demonstrate increases in FGF21 in relationship to BAT gene expression. Relative reductions in FGF21 in those receiving long-term LSM relate to overall improvements in energy expenditure parameters. In contrast, irisin levels are elevated in HIV-infected subjects, but are not influenced by LSM nor associated with BAT gene expression.

High-density lipoprotein-mediated cholesterol efflux capacity is improved by treatment with antiretroviral therapy in acute human immunodeficiency virus infection.

BACKGROUND: Individuals infected with human immunodeficiency virus (HIV) have decreased high-density lipoprotein (HDL)-cholesterol and increased cardiovascular disease (CVD). Reverse cholesterol transport from macrophages may be inhibited by HIV and contribute to increased CVD. Human studies have not investigated longitudinal effects of HIV and antiretroviral therapy (ART) on cholesterol efflux. METHODS: Subjects with acute HIV infection were randomized to ART or not. Cholesterol efflux capacity was determined ex vivo after exposure of murine macrophages to apolipoprotein B-depleted patient sera obtained at baseline and after 12 weeks. RESULTS: After 12 weeks, HIV RNA decreased most in subjects randomized to ART. Available data on cholesterol demonstrated that efflux capacity from Abca1(+/+) macrophages was increased most by sera obtained from ART-treated subjects (20.5% ± 5.0% to 24.3 % ± 6.9%, baseline to 12 weeks, P = .007; ART group [n = 6] vs 18.0 % ± 3.9% to 19.1 % ± 2.9%, baseline to 12 weeks, P = .30; untreated group [n = 6] [P = .04 ART vs untreated group]). Change in HIV RNA was negatively associated with change in Abca1(+/+) macrophage cholesterol efflux (r = - 0.62, P = .03), and this finding remained significant (P = .03) after controlling for changes in HDL-cholesterol, CD4(+) cells, and markers of monocyte or macrophage activation. CONCLUSIONS: In subjects acutely infected with HIV, ATP-binding cassette transporter A1-mediated cholesterol efflux was stimulated to a greater degree over time by apolipoprotein B-depleted serum from subjects randomized to ART. The improvement in cholesterol efflux capacity is independently related to reduction in viral load.

Increased coronary atherosclerosis and immune activation in HIV-1 elite controllers.

HIV-1 elite controllers spontaneously maintain suppressed levels of viremia, but exhibit significant immune activation. We investigated coronary atherosclerosis by coronary computed tomography angiography (CTA) in elite controllers, nonelite controller, chronically HIV-1 infected, antiretroviral therapy (ART)-treated patients with undetectable viral load ('chronic HIV'), and HIV-negative controls. Prevalence of atherosclerosis (78 vs. 42%, P < 0.05) and markers of immune activation were increased in elite controllers compared with HIV-negative controls. sCD163, a monocyte activation marker, was increased in elite controllers compared with chronic HIV-1 (P < 0.05) and compared with HIV-negative controls (P < 0.05). These data suggest a significant degree of coronary atherosclerosis and monocyte activation among elite controllers.

Receptor activator of nuclear factor-κB ligand (RANKL) and its relationship to coronary atherosclerosis in HIV patients.

HIV-infected individuals have an increased prevalence of coronary artery disease. Receptor activator of nuclear factor-κB ligand (RANKL) and osteoprotegerin have been postulated as mediators of vascular calcification. 78 HIV-infected men and 32 healthy controls without history of coronary artery disease were prospectively recruited to undergo cardiac computed tomography and computed tomography angiography to assess coronary artery calcium and plaque burden. Soluble receptor activator of nuclear factor-κB ligand was lower in HIV-infected individuals than controls [2.52 (1.08-3.98) vs. 3.33 (2.44-4.64) pg/mL, P = 0.01, median (IQR) respectively]. Soluble receptor activator of nuclear factor-κB ligand was negatively associated with the number of coronary segments with plaque (Spearman ρ = -0.41, P < 0.001) and Agatston calcium score (ρ = -0.30, P < 0.01) in HIV-infected individuals even after adjusting for traditional cardiovascular risk factors.

Arterial inflammation in patients with HIV.

CONTEXT: Cardiovascular disease is increased in patients with human immunodeficiency virus (HIV), but the specific mechanisms are unknown. OBJECTIVE: To assess arterial wall inflammation in HIV, using 18fluorine-2-deoxy-D-glucose positron emission tomography (18F-FDG-PET), in relationship to traditional and nontraditional risk markers, including soluble CD163 (sCD163), a marker of monocyte and macrophage activation. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of 81 participants investigated between November 2009 and July 2011 at the Massachusetts General Hospital. Twenty-seven participants with HIV without known cardiac disease underwent cardiac 18F-FDG-PET for assessment of arterial wall inflammation and coronary computed tomography scanning for coronary artery calcium. The HIV group was compared with 2 separate non-HIV control groups. One control group (n = 27) was matched to the HIV group for age, sex, and Framingham risk score (FRS) and had no known atherosclerotic disease (non-HIV FRS-matched controls). The second control group (n = 27) was matched on sex and selected based on the presence of known atherosclerotic disease (non-HIV atherosclerotic controls). MAIN OUTCOME MEASURE: Arterial inflammation was prospectively determined as the ratio of FDG uptake in the arterial wall of the ascending aorta to venous background as the target-to-background ratio (TBR). RESULTS: Participants with HIV demonstrated well-controlled HIV disease (mean [SD] CD4 cell count, 641 [288] cells/µL; median [interquartile range] HIV-RNA level, <48 [<48 to <48] copies/mL). All were receiving antiretroviral therapy (mean [SD] duration, 12.3 [4.3] years). The mean FRS was low in both HIV and non-HIV FRS-matched control participants (6.4; 95% CI, 4.8-8.0 vs 6.6; 95% CI, 4.9-8.2; P = .87). Arterial inflammation in the aorta (aortic TBR) was higher in the HIV group vs the non-HIV FRS-matched control group (2.23; 95% CI, 2.07-2.40 vs 1.89; 95% CI, 1.80-1.97; P < .001), but was similar compared with the non-HIV atherosclerotic control group (2.23; 95% CI, 2.07-2.40 vs 2.13; 95% CI, 2.03-2.23; P = .29). Aortic TBR remained significantly higher in the HIV group vs the non-HIV FRS-matched control group after adjusting for traditional cardiovascular risk factors (P = .002) and in stratified analyses among participants with undetectable viral load, zero calcium, FRS of less than 10, a low-density lipoprotein cholesterol level of less than 100 mg/dL (<2.59 mmol/L), no statin use, and no smoking (all P ≤ .01). Aortic TBR was associated with sCD163 level (P = .04) but not with C-reactive protein (P = .65) or D-dimer (P = .08) among patients with HIV. CONCLUSION: Participants infected with HIV vs noninfected control participants with similar cardiac risk factors had signs of increased arterial inflammation, which was associated with a circulating marker of monocyte and macrophage activation.

Soluble CD163, a novel marker of activated macrophages, is elevated and associated with noncalcified coronary plaque in HIV-infected patients.

BACKGROUND: Pro-inflammatory monocytes/macrophages may contribute to increased atherosclerosis in human immunodeficiency virus (HIV)-infected patients. We investigate--to our knowledge, for the first time--sCD163 and other markers of monocyte activation in relationship to atherosclerotic plaque in HIV-infected patients. METHODS: One hundred two HIV-infected and 41 HIV-seronegative men with equivalent cardiovascular risk factors and without history of coronary artery disease were prospectively recruited and underwent computed tomography coronary angiography. RESULTS: sCD163 levels and presence of plaque were significantly higher among antiretroviral-treated subjects with undetectable HIV RNA levels, compared with seronegative controls (1172 ± 646 vs. 883 ± 561 ng/mL [P = .02] for sCD163 and 61% vs. 39% [P = .03] for presence of plaque). After adjusting for age, race, lipids, blood pressure, glucose, smoking, sCD14, and HIV infection, sCD163 remained independently associated with noncalcified plaque (P = .008). Among HIV-infected patients, sCD163 was associated with coronary segments with noncalcified plaque (r = 0.21; P = .04), but not with calcium score. In contrast, markers of generalized inflammation, including C-reactive protein level, and D-dimer were not associated with sCD163 or plaque among HIV-infected patients. CONCLUSIONS: sCD163, a monocyte/macrophage activation marker, is increased in association with noncalcified coronary plaque in men with chronic HIV infection and low or undetectable viremia. These data suggest a potentially important role of chronic monocyte/macrophage activation in the development of noncalcified vulnerable plaque. CLINICAL TRIAL REGISTRATION: NCT00455793.

Increased coronary artery calcium score and noncalcified plaque among HIV-infected men: relationship to metabolic syndrome and cardiac risk parameters.

OBJECTIVE: In this study, the effects of traditional cardiac risk factors on coronary artery calcium (CAC) score and presence of plaque, including noncalcified plaque, measured by computed tomography coronary angiography, were compared among HIV-infected and non-HIV-infected subjects, with respect to the presence of the metabolic syndrome (MS). DESIGN AND METHODS: HIV-infected men recruited for the presence of the MS (HIV + MS, n = 27) were compared with 2 control groups, HIV-infected men recruited without regard to metabolic criteria (HIV, n = 87), and HIV-negative control men (C, n = 40), also recruited without regard to any metabolic criterion. RESULTS: All 3 groups were similar in age, demographic parameters, and smoking. MS was seen in 100% of the HIV + MS group, compared with 28% in the HIV-infected control group and 11% in the HIV-negative controls. HIV + MS subjects had higher mean CAC score than HIV-infected controls (72 ± 25 vs. 30 ± 8, P = 0.04, HIV + MS vs. HIV) and HIV-negative controls (72 ± 25 vs. 18 ± 7; P = 0.02, HIV + MS vs. C). With respect to CAC, only the HIV + MS group had increased CAC compared with non-HIV. In contrast, both HIV groups demonstrated an increased prevalence of plaque [63% vs. 38%, P = 0.04 (HIV + MS vs. C) and 59% vs. 38%, P = 0.02, (HIV vs. C)] and increased number of noncalcified plaque segments compared with the HIV-negative group [1.26 ± 0.31 vs. 0.45 ± 0.16, P = 0.01 (HIV + MS vs. C); 1.02 ± 0.18 vs. 0.45 ± 0.16, P = 0.04 (HIV vs. C)]. Plaque and noncalcified plaque did not differ significantly between the HIV groups. CONCLUSIONS: Metabolic abnormalities in HIV patients are specifically associated with increased coronary artery calcification, whereas HIV itself or other factors may be associated with the development of noncalcified lesions.

Increased epicardial adipose tissue volume in HIV-infected men and relationships to body composition and metabolic parameters.

Epicardial fat accumulation may have important clinical consequences, yet little is known regarding this depot in HIV patients. We compared epicardial fat volume in 78 HIV-infected men and 32 HIV-negative controls. Epicardial fat volume was higher in HIV-infected patients than that in controls (P = 0.04). In HIV patients, epicardial fat volume was strongly associated with visceral adipose tissue area (rho = 0.76, P < 0.0001), fasting glucose (rho = 0.41, P = 0.001) and insulin (rho = 0.44, P = 0.0003). Relationships with glucose and insulin remained significant controlling for age, race, BMI, adiponectin, visceral adipose tissue and antiretroviral therapy. Epicardial fat may be an important fat depot in HIV-infected patients.

Increased prevalence of subclinical coronary atherosclerosis detected by coronary computed tomography angiography in HIV-infected men.

OBJECTIVE: The degree of subclinical coronary atherosclerosis in HIV-infected patients is unknown. We investigated the degree of subclinical atherosclerosis and the relationship of traditional and nontraditional risk factors to early atherosclerotic disease using coronary computed tomography angiography. DESIGN AND METHODS: Seventy-eight HIV-infected men (age 46.5 +/- 6.5 years and duration of HIV 13.5 +/- 6.1 years, CD4 T lymphocytes 523 +/- 282; 81% undetectable viral load), and 32 HIV-negative men (age 45.4 +/- 7.2 years) with similar demographic and coronary artery disease (CAD) risk factors, without history or symptoms of CAD, were prospectively recruited. 64-slice multidetector row computed tomography coronary angiography was performed to determine prevalence of coronary atherosclerosis, coronary stenosis, and quantitative plaque burden. RESULTS HIV-infected men demonstrated higher prevalence of coronary atherosclerosis than non-HIV-infected men (59 vs. 34%; P = 0.02), higher coronary plaque volume [55.9 (0-207.7); median (IQR) vs. 0 (0-80.5) microl; P = 0.02], greater number of coronary segments with plaque [1 (0-3) vs. 0 (0-1) segments; P = 0.03], and higher prevalence of Agatston calcium score more than 0 (46 vs. 25%, P = 0.04), despite similar Framingham 10-year risk for myocardial infarction, family history of CAD, and smoking status. Among HIV-infected patients, Framingham score, total cholesterol, low-density lipoprotein, CD4/CD8 ratio, and monocyte chemoattractant protein 1 were significantly associated with plaque burden. Duration of HIV infection was significantly associated with plaque volume (P = 0.002) and segments with plaque (P = 0.0009) and these relationships remained significant after adjustment for age, traditional risk factors, or duration of antiretroviral therapy. A total of 6.5% (95% confidence interval 2-15%) of our study population demonstrated angiographic evidence of obstructive CAD (>70% luminal narrowing) as compared with 0% in controls. CONCLUSION: Young, asymptomatic, HIV-infected men with long-standing HIV disease demonstrate an increased prevalence and degree of coronary atherosclerosis compared with non-HIV-infected patients. Both traditional and nontraditional risk factors contribute to atherosclerotic disease in HIV-infected patients.

Reduced growth hormone secretion is associated with increased carotid intima-media thickness in obesity.

CONTEXT: Obesity is associated with reduced GH. OBJECTIVE: The aim of the study was to determine whether reduced GH is associated with increased carotid intima-media thickness (cIMT) in obesity. DESIGN: A total of 102 normal-weight and obese men and women without known hypopituitarism were studied. Subjects underwent GH stimulation testing with GHRH-arginine. Lipid profile, inflammatory markers, oral glucose tolerance test, abdominal computed tomography, dual-energy x-ray absorptiometry, and cIMT were measured. Relative GH deficiency was defined as peak GH of 4.2 microg/liter or less. Subjects were separated based on BMI and GH testing into three groups: normal weight, obese GH sufficient (GHS), and obese relative GH deficient (GHD). Age, gender, and race were similar between the groups. BMI, percentage body fat, and visceral adiposity did not differ between obese GHS and relative GHD. RESULTS: Peak GH was associated with cIMT, IGF-I, high-density lipoprotein, low-density lipoprotein, triglycerides, adiponectin, C-reactive protein, and TNF-alpha (all P < 0.05). Obese GHS subjects had similar cIMT compared to normal-weight subjects (P = not significant), whereas obese GHD subjects had higher cIMT compared to normal-weight subjects (P < 0.05) (normal weight, 0.645 +/- 0.023, vs. obese GHS, 0.719 +/- 0.021, vs. obese GHD, 0.795 +/- 0.063 mm; P = 0.01 by ANOVA). Similar results were seen in sensitivity analyses with less stringent cutoffs (< 5, < or = 8, < 9 microg/liter) to define GHD. In multivariate modeling, peak GH remained significantly associated with cIMT after controlling for age, gender, race, tobacco, blood pressure, cholesterol, and fasting glucose (R(2) for model, 0.35; P < 0.0001). CONCLUSIONS: These results suggest that reduced GH secretion is associated with a more abnormal metabolic phenotype in obesity, characterized by increased cIMT, dyslipidemia, insulin resistance, and inflammation.

Increased aldosterone among HIV-infected women with visceral fat accumulation.

Increased aldosterone has been associated with obesity and the metabolic syndrome in non-HIV-infected individuals, but aldosterone has not been investigated among HIV-infected patients with increased visceral adipose tissue (VAT). Twenty-four-hour urine aldosterone was assessed among age and BMI-matched HIV-infected women with increased VAT, HIV-infected women without increased VAT and healthy controls. Twenty-four hour urine aldosterone was higher in HIV-infected women with increased VAT and was associated with SBP, VAT and hemoglobin A1c. Increased aldosterone may contribute to the detrimental effects of excess visceral adiposity on blood pressure and glucose homeostasis among HIV patients.

Relationship of peak growth hormone to cardiovascular parameters, waist circumference, lipids and glucose in HIV-infected patients and healthy adults.

OBJECTIVE: Relative growth hormone (GH) deficiency is highly prevalent in patients with HIV. The purpose of this study was to investigate relationships of GH to metabolic and anthropometric parameters in HIV patients and non-HIV controls. DESIGN: Peak GH and metabolic parameters were assessed in a cross-sectional study of 191 HIV patients and 62 age and BMI-matched healthy controls. METHODS: Peak GH was assessed by GHRH/arginine stimulation testing. RESULTS: HIV patients demonstrated similar BMI, but increased waist circumference (WC) and reduced peak GH to GHRH/arginine compared with control subjects [median = 12.4 (interquartile range: 6.3-24.8) vs. 21.3 (8.8, 34.5) µg/l, P = 0.006, HIV vs. control]. Among HIV and non-HIV groups, peak GH was inversely associated with WC (rho = -0.44, P < 0.0001; rho = -0.63, P < 0.0001; HIV patients and controls, respectively), blood pressure (rho = -0.17, P = 0.02; rho = -0.36, P = 0.004), triglycerides (rho = -0.37, P < 0.0001; rho = -0.43, P = 0.001), glucose (rho = -0.34, P < 0.0001; rho = -0.30, P = 0.02), insulin (rho = -0.43, P < 0.0001; rho = -0.60, P < 0.0001) and CRP (rho= -0.29, P < 0.0001; rho = -0.59, P < 0.0001). Among HIV patients, the inverse association between peak GH and fasting glucose remained significant (ß = -0.006 mmol/l change in glucose per µg/l change in GH, P = 0.004) controlling for age, gender, race, BMI, WC, protease inhibitor (PI) and nucleoside reverse transcriptase inhibitors. Similarly, the inverse association between peak GH and triglycerides remained significant (ß = -0.01 mmol/l change in triglycerides per µg/l change in GH, P = 0.02) controlling for age, gender, race, BMI, WC, PI and lipid-lowering medications. HIV men with peak GH < 7.5 µg/l demonstrated higher BMI, WC, SBP, triglycerides, glucose and CRP. CONCLUSIONS: Reduced GH secretion is independently associated with dyslipidaemia and higher glucose, among HIV patients with abdominal fat accumulation.