In this issue:

 q January 2008 in Review

• New cardiovascular disease risk score estimate developed by Framingham Heart Study
• Differential association of traditional risk factors with varying coronary atherosclerosis plaque composition
• Multidetector CT Angiography identifies significant coronary artery disease even in presence of normal myocardial perfusion 
• Total cholesterol is the best predictor of carotid plaque lipid core
• Both CACS and CIMT predict cardiovascular diseases in elderly individuals
• A normal CACS test is associated with 100% likelihood of normal myocardial perfusion in patients admitted to chest pain unit 
• Carotid artery elasticity associated with risk factors among individuals with normal levels of carotid atherosclerosis
• Myeloperoxidase is a better predictor of hard CVD events among patients with peripheral artery disease
• A higher fitness level is associated with at least 50% reduction in all  cause mortality
• Effect of high fat diet on subclinical atherosclerosis is attenuated with moderate alcohol consumption 
• Blood pressure treatment and intensification among diabetic patients inversely related to the duration of last board certification 
• Flu shots reduce risk of clinical CVD event among patients with stable coronary artery disease 
  

D'Agostino RB Sr, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel WB. General Cardiovascular Risk Profile for Use in Primary Care. The Framingham Heart Study. Circulation. 2008 Jan 22 [Epub ahead of print]

Aim:
To develop a new risk stratification model to predict cardiovascular disease (CVD) in men and women free of CVD and compare its utility with current risk stratification models

Methods:

• The study population consisted of 8491 (4522 women and 3969 men, age range=30-74 years) were evaluated in the study who were free of CVD during 1968-1987 in the Framingham Heart Study (FHS).
• The primary endpoint was a cardiovascular event that included coronary heart disease, cerebrovascular events, peripheral artery disease, and heart failure.
• The following risk factors were evaluated: age, diabetes, and smoking, systolic blood pressure, use of antihypertensive medications, total cholesterol, and HDL cholesterol in the risk model.
• C statistics were used to compare the newly developed model with the one currently used as advocated by NCEP ATP III Panel.

Results:

• The study follow up was 12 years of follow-up during which 1174 participants (456 women) developed a first CVD event.
• The general CVD algorithm demonstrated good discrimination with C statistic 0f 0.76 in men and 0.79 in women
• The current used Framingham CHD risk model was inferior in predicting CVD risk with c statistics of 0.76 in men and 0.78 in women (0.756 [95% CI, 0.739, 0.773] in men. The respective differences were statistically significant (all p values<0.05).
• In the newly developed model, the highest sex-specific quintiles had a sensitivity and specificity of 49% & 85% in men. The respective values were 60% and 84%. In comparison the sensitivity and specificity for the currently used risk models were 47% & 85% in men and 56% and 83% in women (p values <0.05 for differences)
• Addition of risk factors such as LDL cholesterol diastolic blood pressure, body mass index, and triglycerides did not significantly improve the model

SHAPE Perspective:

• The newly developed risk estimation from the FHS appears to better predict CVD risk in men and women than the current risk stratification strategies.
• A significant limitation of the study is that although family history of premature CHD has been repeatedly shown to significantly associate with adverse cardiovascular outcome (even in the FHS) it was not considered in the risk model.
• In spite of increased improvement, it was unable to predict a CVD event in nearly 50% men and 40% women and as result potentially support needs for further risk stratification strategies (use of biomarkers or imaging modalities) to identify the risk accurately in these vulnerable patients.

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q Differential association of traditional risk factors with varying coronary atherosclerosis plaque composition

Bamberg F, Dannemann N, Shapiro MD, Seneviratne SK, Ferencik M, Butler J, Koenig W, Nasir K, Cury RC, Tawakol A, Achenbach S, Brady TJ, Hoffmann U. Association Between Cardiovascular Risk Profiles and the Presence and Extent of Different Types of Coronary Atherosclerotic Plaque as Detected by Multidetector Computed Tomography. Arterioscler Thromb Vasc Biol. 2008 Jan 3 [Epub ahead of print]

Aim:
The aim of this study was to assess the relationship of traditional cardiovascular risk factors and the presence as well as extent of different coronary atherosclerotic plaque composition

Methods:

• The study population consisted of a cross-sectional study of consecutive subjects who presented with chest pain
• The finals study population consisted of only patients who no history of coronary artery disease (CAD) and did not develop acute coronary syndrome.
• Contrast-enhanced 64-slice coronary MDCT was performed to determine the presence of non-calcified coronary atherosclerotic plaque (NCAP), mixed coronary atherosclerotic plaque (MCAP), and calcified coronary atherosclerotic plaque (CAP) for each coronary segment.

Results:

q Multidetector CT angiography identifies significant coronary artery disease even in presence of normal myocardial perfusion

van Werkhoven JM, Schuijf JD, Jukema JW, Kroft LJ, Stokkel MP, Dibbets-Schneider P, Pundziute G, Scholte AJ, van der Wall EE, Bax JJ. Anatomic correlates of a normal perfusion scan using 64-slice computed tomographic coronary angiography. Am J Cardiol. 2008 Jan 1;101(1):40-5

Aim:
To explore the range of anatomic abnormalities with multi-detector CT angiography (MDCTA) among patients with normal myocardial perfusion imaging (MPI) result.

Methods:

• 180 patients (suspected CAD) underwent MPI and 64-slice MSCT sequentially in random order.
• Segmental myocardial perfusion was analyzed quantitatively (quantitative gated SPECT software)
• Normal MPI was considered if tracer activity >75%
• Final Study population consisted of 97 patient considered as having normal MPI.

Results:

• Among patients with normal MPI, 38 (39%) had no detectable atherosclerosis.
• On the other hand 59 patients had detectable atherosclerosis (61%), with 39% having non obstructive CAD, 19% had obstructive CAD and 4% were considered high risk (3 vessel disease and/or left main disease).
• Average coronary calcium score in patients with a completely normal MSCT scan result was significantly lower than the average calcium score in patients with nonobstructive or obstructive CAD (3.3 ± 11.1 vs 223 ± 363.6 and 306.8 ± 323.3, respectively).

SHAPE Perspective:

• Majority of patients with normal MPI have some underlying atherosclerosis with a wide range of atherosclerotic burden
• Although a normal MPI is associated with a very low risk of future CVD clinical event, however it may potentially miss significant CAD in nearly 20% of patients who may benefit from further aggressive medical interventions.
• Further studies are needed to elucidate the prognostic value of MDCTA abnormalities among patients with a normal myocardial perfusion study.

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q Total cholesterol is the best predictor of carotid plaque lipid core

Wasserman BA, Sharrett AR, Lai S, Gomes AS, Cushman M, Folsom AR, Bild DE, Kronmal RA, Sinha S, Bluemke DA. Risk Factor Associations With the Presence of a Lipid Core in Carotid Plaque of Asymptomatic Individuals Using High-Resolution MRI. The Multi-Ethnic Study of Atherosclerosis (MESA). Stroke. 2008 Jan 3 [Epub ahead of print

Aim:
Assess the relationship between traditional cardiovascular risk factors with lipid rich composition of the carotid arteries in individuals free of known cardiovascular diseases.

Methods:

• The study population consisted of participants from the Multiethnic Study of Atherosclerosis who were pre-selected based on elevated carotid artery intimal thickness by ultrasound.
• These individuals underwent high-resolution black blood MRI images through their carotid plaque before and after the intravenous administration of gadodiamide (0.1 mmol/kg).
• The authors analyzed only plaques with a maximum thickness =1.5 mm by and assessed cross-sectional risk factor associations with lipid core presence by multivariable logistic regression.

Results:

• The final study population consisted of only 214 participants.
• A lipid core was observed in 151 (71%) of the plaques.
• In multivariate adjusted analysis, the odds ratio of having a lipid core for participants in the middle and highest tertiles of total cholesterol levels were 2.76 (95% CI: 1.01 to 7.51) and 4.63 (95% CI: 1.56 to 13.75), respectively compared to those with lipids in the lowest levels.
• None of the other risk factors such as age, hypertension, diabetes, smoking, body mass index, and statin use were not associated with lipid core

SHAPE Perspective:

• In this novel study levels of total cholesterol were 2-4 times more likely to be associated with increased lipid core size.
• Interestingly no other risk factors were associated with plaque burden in this study, which may be potentially a limitation of the small sample size of the study
• In addition it must be kept in mind that the study results may not apply to the general population as the group was pre-selected based on advance carotid IMT levels.
• The additional value of measuring lipid core on MRI need to be evaluated in terms of its ability to predict CVD events as well whether it can be used a s a surrogate for assessing efficacy of lipid lowering treatments.

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q Both CACS and CIMT predict cardiovascular diseases in elderly individuals

Newman AB, Naydeck BL, Ives DG, Boudreau RM, Sutton-Tyrrell K, O'Leary DH, Kuller LH. Coronary artery calcium, carotid artery wall thickness, and cardiovascular disease outcomes in adults 70 to 99 years old. Am J Cardiol. 2008 Jan 15;101(2):186-92

Aim:
Assess the prognostic value of assessing both coronary artery calcium (CAC) and carotid intimal thickness (CIMT) in elderly individuals

Method:

• The study population consisted of 559 men and women>70 years of age (mean age 84±4 years) who CAC score assessed by electron beam computerized tomographic scan and common and internal carotid artery intimal medial wall thickness (CCA-IMT and ICA-IMT) by carotid ultrasound between 1998 and 2000.
• The primary study was incident cardiovascular disease events.
• The predictive value of CAC and CIMT were assessed according to their respective quartiles.

Result:

• The study cohort was followed for 5 years
• Among this elderly population the authors observed 127 first total cardiovascular disease events (48 myocardial infarctions or coronary heart disease deaths, and 28 fatal or nonfatal strokes).
• After adjusting for CVD risk factors as compared to those with CAC in the first quartile (0-56) the hazard ratios (95%CI) for any CVD event with increasing quartiles were 1.56 (0.86-2.8), 2.04 (1.14-3.64) and 2.12 (1.16-3.85)
• The respective hazard ratios for increasing CIMT quartiles were 0.92 (0.49-1.46), 0.75 (0.43-1.30) and 2.30 (1.30-4.08).
• Similar patterns were seen for association with CHD and stroke, although there was a trend for the CIMT to be more specific for stroke and trend of CAC to be more predictive of myocardial infarction.
• The areas under the curve for prediction of CVD events with CAC were 0.68 compared to 0.65 with CIMT.

SHAPE Perspective:

• This study highlights that even among elderly patients (with mean age of 84 years) a higher burden of atherosclerosis as measured by CAC or IMT were able to predict adverse CVD outcomes.
• Although all of these patients should be considered candidates for primary prevention, it appears that testing for subclinical atherosclerosis may improve our ability to identify those with higher underlying CVD risk in order to initiate more stringent and pharmacological preventive strategies in this vulnerable population.
• The combined effect of elevated CIMT with CAC was not reported in this study and is yet to be seen whether the 2 may add information in predicting CVD than either alone.

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q A normal CAC test is associated with 100% likelihood of normal myocardial perfusion in patients admitted to chest pain unit

Esteves FP, Sanyal R, Santana CA, Shaw L, Raggi P. Potential impact of noncontrast computed tomography as gatekeeper for myocardial perfusion positron emission tomography in patients admitted to the chest pain unit. Am J Cardiol. 2008 Jan 15;101(2):149-52.

Aim:
To evaluate the ability of absence of coronary artery calcium (CAC) to predict a normal myocardial perfusion in patients admitted to chest pain unit (CPU) to rule out acute coronary syndrome

Methods:

• The study consisted of 84 consecutive patients (33 men; mean age 62 ± 14.8 years) who were admitted to the CPU at a single tertiary hospital
• All of these patients had a negative normal or nondiagnostic electrocardiograms on admission and 2 negative sets of cardiac enzymes (troponin I).
• Subsequently these patients had adenosine stress Rb-82 PET/CT myocardial perfusion imaging as well CAC testing.

Results:

• CAC was observed in 50/84 (60%) patients
• Overall 34 (40%) had no CAC; all of them had a normal adenosine stress Rb-82 myocardial perfusion PET in 34 of 34 patients, yielding a negative predictive value of 100%.
• Overall 13 patients (15%) had myocardial perfusion defects. All of these patients had detectable CAC resulting in sensitivity of 100%.
• The positive and negative predictive value of CAC in detecting myocardial perfusion defects were 26% and 48% respectively.

SHAPE Perspective:

• This study further ads to the ability of CAC zero to identify individuals at very low risk of CVD as demonstrated by lack of myocardial perfusion defects in these patients.
• CAC testing can be employed as a potential gatekeeper to identify individuals admitted to the emergency department with chest pain and normal or nondiagnostic electrocardiograms.

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q Carotid artery elasticity associated with risk factors among individuals with normal levels of carotid atherosclerosis

Okimoto H, Ishigaki Y, Koiwa Y, Hinokio Y, Ogihara T, Suzuki S, Katagiri H, Ohkubo T, Hasegawa H, Kanai H, Oka Y. A novel method for evaluating human carotid artery elasticity: possible detection of early stage atherosclerosis in subjects with type 2 diabetes. Atherosclerosis. 2008 Jan;196(1):391-7

Aim:
To assess whether carotid artery elasticity correlates well with risk factors in patients with type 2 diabetes mellitus and more importantly among those with normal carotid IMT levels

Methods: 

• The study population consisted of 242 (62±12 years, 54% males) type 2 diabetes mellitus (DM) patients
• In these young study participants ankle brachial pressure index (ABI) brachial ankle pulse wave velocity (baPWV) and carotid initimal medial thickness (CIMT) were measured as measures of subclinical atherosclerotic disease.
• In addition real-time measurement of regional elasticity in the carotid artery wall was measured with ultrasound diagnostic equipment

Results:

• In the overall study elasticity correlated with age (r = 0.340, p < 0.01), duration of diabetes (r = 0.136, p < 0.05) and blood pressure, both systolic (r = 0.430, p < 0.01) and diastolic (r = 0.147, p < 0.05).
• In multivariate analysis increasing age, systolic blood pressure and hyperlipidemia to be independently associated with elasticity values.
• Carotid artery elasticity demonstrated significant positive correlations with max IMT (r = 0.291, p < 0.01) and baPWV (r = 0.345, p < 0.01) whereas no relationship was observed with the ABI value (r = -0.087, p = 0.176).
• In sub-analysis among subjects with max IMT <1.1 mm (n = 82), only age-adjusted carotid artery elasticity correlated with an increasing number of risk factors (p<0.05)

SHAPE Perspective:

• These study finding suggests this novel method of assessing carotid elasticity has the potential for detecting individuals at higher risk factors in its early stage of atherosclerotic disease.
• Further studies are needed to fully elucidate the role of carotid elasticity as a predictor of rapid underlying atherosclerosis progression and more importantly identifying those likely to suffer a clinical event in order to establish its role in cardiovascular disease prevention paradigms.

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q Myeloperoxidase is a better predictor of hard CVD events among patients with peripheral artery disease

Brevetti G, Schiano V, Laurenzano E, Giugliano G, Petretta M, Scopacasa F, Chiariello M. Myeloperoxidase, but not C-reactive protein, predicts cardiovascular risk in peripheral arterial disease. Eur Heart J. 2008 Jan;29(2):224-230

Aim:
To assess the role inflammation in peripheral arterial disease (PAD) in predicting adverse CVD outcomes

Methods:

• The study population consisted of 152 patients with documented PAD as determined by an ankle brachial index (ABI) < 0.90.
• Serum samples were obtained to determine underlying levels of C reactive protein CRP) and myeloperoxidase (MPO)
• The primary outcome of this study was fatal/non-fatal acute myocardial infarction and stroke.

Results:

• The patients were followed for a median of 17.5 (12.0Ð24.0) months.
• Overall 17 events (11%) were recorded in the prospective follow-up (10 had an acute myocardial infarction (50% were fatal) and seven had stroke)
• The MPO value that was associated with the maximum sum of the specificity and sensitivity in predicting the outcome was 179.4 pM. This cutoff of MPO as associated with an adverse outcome with a hazard ratio of 6.80 (95% CI 1.20Ð38.69, P = 0.031).
• Receiving operator curve analyses failed to identify revealed no significant contribution of CRP in predicting the outcome with an area under the curve of 0.53 (95% CI 0.41Ð0.65, P = 0.670). The hazard ratio for any event with CRP>1 mg/dl was 0.76 (95% CI 0.08Ð7.41, P = 0.810)

SHAPE Perspective:

• Individuals with reduced ABI are at a significant risk of CVD events as noted by 11% event rate in nearly one and half year follow-up in this study.
• Among these high risk groups, an elevated MPO can further identify those likely to suffer an acute event in the short term and thus may promote further aggressive treatments and frequent follow-up.
• However no role of CRP was noted in this vulnerable population.
• Further investigations are needed to assess whether similar findings are also observed in patients free of significant subclinical atherosclerotic diseases.

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q A higher fitness level is associated with at least 50% reduction in all cause mortality

Kokkinos P, Myers J, Kokkinos JP, Pittaras A, Narayan P, Manolis A, Karasik P, Greenberg M, Papademetriou V, Singh S.Exercise Capacity and Mortality in Black and White Men. Circulation. 2008 Jan 22 [Epub ahead of print]

Aim:
To assess the association between exercise capacity and mortality among a large cohort of Caucasian and African Americans

Methods:

• The authors prospectively followed 6749 black (age, 58±11 years) and 8911 white (age=60±11 years) male veterans with and without cardiovascular disease who successfully completed a treadmill exercise test 2 Veterans Affairs Medical Centers
• Subjects were followed up for all-cause mortality for 8±5 years
• Fitness categories were based on peak metabolic equivalents (METs) achieved.
• All cause mortality was the primary outcome and the deaths were monitored by the Office of National Statistics as well as from the Veterans Affairs Beneficiary Identification and Record Locator System File.

Results:

• A total of 3912 deaths occurred, with an average annual mortality of 3.3%.
• Overall the mortality was 11% higher in blacks than in whites (hazard ratio, 1.11; 95% confidence interval: 1.01 to 1.18) after taking into account traditional risk factors and medication history
• Exercise capacity was the strongest predictor of mortality with the area under the curve in ROC analysis of 0.71. In comparison the AUC for age was 0.67, 0.50 for CVD risk factors and 0.41 for BMI.
• In this study as compared to individuals in the lowest fitness category (< 5 METS), those in the highest exercise capacity (> 10 METS) had a 70% lower risk of all-cause death.
• The beneficial effect was also seen in men also in the moderate fitness category (7.1 - 10 METs) with a 50% lower mortality compared to those with the least fitness levels.

SHAPE Perspective:

• This study further provides support that increased physical activity and as a result improved physical fitness is one of the most effective and cheap interventions in reducing overall risk of CVD and death.
• In addition, the study underscores and reminds the prognostic value of assessing exercise capacity in identifying high risk individuals in need for aggressive preventive interventions.

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q Effect of high fat diet on subclinical atherosclerosis is attenuated with moderate alcohol consumption  

Merchant AT, Kelemen LE, de Koning L, Lonn E, Vuksan V, Jacobs R, Davis B, Teo KK, Yusuf S, Anand SS; for the SHARE and SHARE-AP investigators. Interrelation of saturated fat, trans fat, alcohol intake, and subclinical atherosclerosis. Am J Clin Nutr. 2008 Jan;87(1):168-74

Aim:
To examine interrelation of saturated fat, trans fat and alcohol intake, with extent of subclinical atherosclerosis

Methods:

• The study population consisted of 620 persons of Aboriginal, South Asian, Chinese, or European origin aged 35Ð75 years in Canada
• Dietary patterns in these participants was evaluated with self-administered, quantitative food-frequency questionnaires (FFQs)
• Subclinical atherosclerosis as determined by carotid intima medial thickness (CIMT) was measured with carotid B-mode ultrasound

Results:

• The authors noted that for every 10-g/d increase in saturated fat intake, CIMT was 0.03 mm higher (P = 0.01) after taking into account traditional CVD risk factors.
• In a similar fashion each 1-g/d higher intake of trans fat was associated with a 0.03-mm higher IMT (P = 0.02) in risk factor adjusted analyses
• On the other hand the ratio of polyunsaturated to saturated fat was inversely associated with IMT after multivariate adjustment (change in IMT: -0.06 mm; P < 0.01).
• Alcohol intake was inversely related with IMT after multivariate adjustment
• The association of saturated fat intake and IMT strengthened was modified by alcohol intake with greater effect of saturated fats seen among those who never or rarely consumed alcohol.

SHAPE Perspective:

• As noted in this study diets rich in saturated and trans fat intakes are associated with an increased risk of atherosclerosis.
• Alcohol intake appeared to modify and attenuate the effect of saturated fatty intake on the underlying atherosclerotic burden.
• However it must be noted that although moderate alcohol intake has potential beneficial effect on the CVD risk, heavy intake is adversely associated with outcomes such as stroke, hypertension as well addiction.

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q Blood Pressure treatment and intensification among diabetic patients inversely related to the duration of last board certification  

Turchin A, Shubina M, Chodos AH, Einbinder JS, Pendergrass ML. Effect of Board Certification on Antihypertensive Treatment Intensification in Patients With Diabetes Mellitus. Circulation. 2008 Jan 22 [Epub ahead of print]

Aim:                         
To assess the quality of care in patients with diabetes mellitus as measured by frequency of antihypertensive treatment intensification in relationship with duration to physicians' last board certification

Methods:

• The study design was a retrospective cohort study of diabetic patients followed up by internists at 2 major tertiary care hospitals for a period of 5 years from 2000-20005
• The recommended treatment goals of systolic blood pressure (SBP) and diastolic blood pressure (DBP) used was 129 and 84 mm of Hg, respectively.
• The primary outcome of this study was the treatment intensification rate (TIR) which was defined as the ratio of the number of encounters with documented elevated blood pressure and treatment intensification to the total number of encounters with documented elevated blood pressure.
• TIR was related to the years since last board certification

Results:

• Study population consisted of 21,912 adult DM patients (mean age 64 years, 56% females) at least 1 outpatient visit and were not treated by an endocrinologist or a diabetologist.
• In this study the highest frequency of treatment intensification was seen from 26.7% for physicians who were board certified the previous year (27%) vs. 7% for physicians who were board certified 31 years before the visit.
• When stratified according to =10 years vs. >10 years from board certification, the TIR was 23% vs. 17% (p<0.0001)
• In analyses adjusting for patient and visit characteristics as well physician age, The probability of TIR decreased 21% with every decade since the physician's last board certification (p=0.009)

SHAPE Perspective:

• The current study points to the fact that primary care efforts in high risk group patient such as DM is generally lacking.
• The lack of aggressive approach to treatment is directly related to duration of board certification and calls for further need for frequent educational updates in the physician community.
• The study findings provide support to current policies of mandatory re-certification as intensive educational efforts most likely will improve CVD quality of care provided by primary care physicians.

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q Flu shots reduce risk of clinical CVD event among patients with stable coronary artery disease  

Ciszewski A, Bilinska ZT, Brydak LB, Kepka C, Kruk M, Romanowska M, Ksiezycka E, Przyluski J, Piotrowski W, Maczynska R, Ruzyllo W. Influenza vaccination in secondary prevention from coronary ischaemic events in coronary artery disease Eur Heart J. 2008 Jan 10

Aim:
To evaluate the effect of influenza vaccination on the incidence of coronary events in patients with coronary artery disease (CAD)

Methods:

• The study is a double-blind, randomized, placebo controlled, parallel groups study on influenza vaccination in optimally treated coronary patients (age range 30-80 years) with CAD confirmed by coronary angiography.
• 325 patients received the influenza vaccine, and 333 patientÕs placebo.
• These patients were followed for a median follow-up was 298 days.
• Primary endpoint was the cardiovascular death with secondary endpoints of MACE (Cardiovascular death, MI, coronary revascularization: PCI or CABG) as well as Ischemic Coronary Event (MACE, hospitalization for ischemia)

Results:

• The primary endpoint (CVD death) was observed in two patients in the vaccine and in two patients in the placebo group (estimated 12-month cumulative cardiovascular death rate of 0.63% in vaccinated and 0.76% in placebo patients, P = 0.95).
• MACE tended to occur less frequently in the vaccine group (3%) vs. placebo (5.9%) with a HR 0.54 (95% CI: 0.24-1.21, P = 0.13).
• In addition coronary ischemic event rate was significantly lower in the vaccine (6%) vs. controls (9.9%) and a HR of 0.54(95% CI: 0.29-0.99, P = 0.047).

SHAPE Perspective:

• Study finding supports and reinforce the notion that Influenza vaccination should be part of the optimal medical treatment improves in patients with known CAD in order to reduce risk of future CVD events.
• This effect appears to extend beyond the period of viral circulation.
  Whether this effect is mediated through stabilization of atherosclerotic plaque or reducing underlying inflammation needs further explanation.

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1) Jan. in review

- Research highlights

2) Featuring unique 

- SHAPE Perspectives 

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