published_or_final_version / Medicine / Doctoral / Doctor of Philosophy

published_or_final_version / abstract / Pharmacology / Master / Master of Philosophy

published_or_final_version / abstract / Physiology / Doctoral / Doctor of Philosophy

Strong evidence has been found to link the diagnosis of CHD with depression, and patients with all CHD-related diagnoses and co-morbid depression display higher morbidity and mortality from CHD than those individuals without depression. Screening and treatment of depression by cardiology clinicians continues to be limited due to poor symptom recognition and lack of desire to treat perceived primary care conditions in specialty practice. The American Heart Association has designated timely assessment and treatment/referral of depression as primary goals for high-quality evidenced-based cardiology care to improve patient outcomes in CHD.This study employed a quasi-experimental descriptive pretest-posttest study design for the purposes of (1) understanding diagnostic and treatment practices for depression in the presence of CHD by nurse practitioner and physician cardiology providers (n=35) in a large metropolitan private outpatient cardiology practice and; (2) adaptation of a valid and reliable depression screening tool (Patient Health Questionnaire-9) to an existing electronic medical record system for use in the sample practice.Findings from the study showed that even though all providers (100%) believed that depression inhibited patients' ability to make positive CHD risk-reducing lifestyle changes, and the majority (73.7%) felt that depression contributed to the progression of CHD, no formal screening for depression was being performed. Less than half (42.1%) of providers in the sample treated depression in their clinic practice, and the large majority (89.5%) referred patients back to primary providers for all depression care.Since 2008 guidelines for depression care by cardiology providers were recommended by the American Heart Association (endorsed by the American Psychiatric Association), it is questionable if these recommendations are filtering down to outpatient cardiology practice. Provider education to improve confidence with depression screening and treatment, and provision of concise easy-to-use care templates in outpatient EMR systems may help to improve compliance with recommendations while maximizing patient outcomes for depressed CHD patients.Advanced practice nurses have been consistently instrumental in the development and management of performance-enhancing processes that improve care quality and patient outcomes. As nursing practice leaders, nurse practitioners should be progressive in supporting implementation of best-practice for depression care in outpatient cardiology practice settings.

The Purpose of this research was to describe relationships between Murdaugh and Verran's (1987) Preventive Behavior Model Concepts in military-affiliated individuals at risk for coronary artery disease. One hundred forty-three subjects were recruited by their primary care physician and were requested to voluntarily complete questionnaires measuring health beliefs, health locus of control, value orientations, and health care activities. Laboratory values and blood pressure were also evaluated. There were significant positive correlations between health beliefs, health locus of control, and value orientations. However, these PBM concepts explained only 13% of the variance in dietary habits, 9% of smoking behaviors, 16% of habitual physical activity, 4% of cholesterol levels, 2% of diastolic blood pressure, 7% of body mass index, and 21 percent of glucose levels. PBM concepts explained a relatively small amount of the variance in the dependent variables within this sample and the results were not clinically significant.

No description available.

The main purpose of this study is to examine the differences of preventive management utilizations and diabetes complications in Asian Americans and Non-Hispanic whites using multiple years (2002-2013) Behavioral Risk Factor Surveillance System (BRFSS). SAS for complex survey procedures were used to perform the data analysis. Odds ratios (OR) were calculated to compare the prevalence of diabetes complications and preventive management rate in Asian with white. Compared to white, the prevalence of diabetes retinopathy in Asians were higher, while the rates of neuropathy and cardiovascular complications, pneumonia shot, personally management as well as management diabetes with doctors were lower. The prevalence of routine checkup in Asian was not significantly different from the prevalence in white. More attentions should be paid on Asians for diabetes related retinopathy.

Objective: Theoretical and empirical evidence suggests a relationship between Repetitive Thought (RT, e.g. rumination), and depression in patients with Coronary Heart Disease (CHD). To date, cross-sectional studies indicate that rumination is associated with depression in CHD, but additional prospective longitudinal research is required to determine if rumination predicts subsequent depression. This research therefore aimed to test the hypothesis that RT, specifically rumination, is a vulnerability factor for depression over time in a CHD population. It was predicted that RT at baseline would predict depression rates at three month follow-up after controlling for baseline depression and potential confounding factors. Methods: Inpatients and outpatients with a diagnosis of CHD completed self-report questionnaires at baseline (N = 101) and at three month follow-up (N = 85). The data was analysed using a hierarchical multiple regression. Results: Baseline rumination significantly predicted depression at the three month follow-up after controlling for baseline depression and potential confounding factors. Rumination accounted for 8.3% of the variance (p< .001). Subscales of brooding and reflection were also found to be individually predictive of follow-up depression explaining 4% of the variance (p< .005) and 7% of the variance (p< .001) respectively. Conclusion: Findings are consistent with previous prospective and cross-sectional research that indicates that rumination plays a unique role in the maintenance of depression in CHD patients and is an identifiable vulnerability factor.

Introduction There is a pressing clinical need to treat patients with acute coronary syndrome (ACS) timely and efficiently in order to improve their prognosis. Standard tools available in ED, while useful, do not comprehensively characterize ACS for either diagnosis or risk stratification. The role of CMR in ACS is emerging because it allows assessment of both myocardial composition and function. Newer CMR techniques such as: a) T2 W imaging for assessing myocardial oedema and area at risk B) pre contrast T1 mapping techniques for quantitative characterization of the tissue composition, are adding further utility for CMR in ACS. At present the clinical use of these techniques is still limited and further investigations are needed to assess their clinical applicability in ACS patients. Aims The aims of this thesis were several. Firstly we sought to establish a CMR protocol for imaging ACS patients on a 3T CMR scanner. In order to do so, we validated a novel T2 W technique for oedema imaging (T2 prep SSFP) at 3T. Second, we aimed to perform a detailed study of the time course of oedema in ACS patients in order to establish the appropriate imaging time for the assessment of area at risk. Third, by applying T2W acute oedema imaging, we sought to investigate the functional and pathological meaning of complicated remote plaques in patients with multivessel disease. Finally, we aimed to establish whether, in comparison to standard CMR techniques, novel precontrast Tl mapping allows better characterisation of the acutely injured myocardium and whether it can predict long-term functional recovery. Methods The research studies were all performed on a 3T Trio Siemens scanner. In the initial stage of the research, we validated the T2 W technique performing phantom work and scanning both volunteers and patients to assess the uniformity of signal intensity in the myocardium and to establish a threshold based method to post process the images. We then established a CMR protocol for ACS including oedema imaging, T1 mapping imaging, perfusion, functional and late gadolinium enhancement imaging. Patients with acute myocardial infarction (both ST elevation myocardial infarction (STEMI) and non STEMI) were scanned at 4 different time points after the acute event (3 scans within 2 weeks and one at 6 months). All STEMI patients underwent primary percutaneous coronary intervention (PCI) while the non-STEMI patients underwent coronary angiography and for PCI. Results We validated the T2prep SSFP technique at 3T, highlighting its limitations and establishing a threshold of mean ± 2SD to assess myocardial oedema. We found that the optimal imaging window to assess the maximal expression of myocardial oedema was within 1 week from the acute event in patients with ST elevation MI. Also, our results showed a reduction of LGE over time (from acute to chronic) in segments which also showed improvement in contractile function indicating that even segments with transmural LGE assessed in the early hours post event could be viable. By applying these techniques in acute patients with bystander disease undergoing percutaneous coronary intervention, we found that: l) T2W imaging can detect myocardial injury downstream from a vessel identified as "non culprit" 2) in 20% of NSTEMI patients, the angiographic assessment alone failed to identify the culprit vessel. Finally, we found that the diagnostic performance of acute pre-contrast Tl-mapping was at least as good as that ofT2W CMR for detecting myocardial injury. There was a significant relationship between the segmental damaged fraction assessed by either by LGE or T2W, and mean segmental Tl values and the likelihood of improvement of segmental function at 6 months decreased progressively as acute Tl values increased. Conclusions In summary, we defined a stable imaging window for the retrospective evaluation of area at risk and we also indicated that acutely detected LGE does not necessarily equate with irreversible injury and may severely underestimate salvaged myocardium. Furthermore, in NSTEMI patients with multivessel disease, by revealing acute myocardial damage in territories pertaining to vessels not treated acutely, we raised the issue of the need for better tools for the correct identification of the culprit vessel and to stratify patients rather than by angiographic assessment alone. Finally, we demonstrated how pre-contrast Tl mapping allows for assessment of the extent of myocardial damage and how Tl mapping might become an important complementary technique to LGE and T2W for the identification of reversible myocardial injury and the prediction of functional recovery in acute MI.

Background: Recent studies have revealed an association between genetic variants at the ADAMTS7 (a disintegrin-like and metalloprotease with thrombospondin type 1 motif, 7) locus and susceptibility to coronary artery disease (CAD). ADAMTS-7 has been reported to facilitate vascular smooth muscle cell (VSMC) migration and promote neointima formation. We sought to study the functional mechanisms underlying this relationship and to further investigate the role of ADAMTS-7 in atherosclerosis. Methods and Results: In vitro assays showed that the CAD-associated non-synonymous single nucleotide polymorphism rs3825807, which results in a serine to proline (Ser-to- Pro) substitution at residue 214 in the ADAMTS-7 pro-domain, affected ADAMTS-7 prodomain cleavage. Immunohistochemical analyses showed that ADAMTS-7 localised to vascular smooth muscle cells (VSMCs) and endothelial cells (ECs) in human coronary and carotid atherosclerotic plaques. Cell migration assays demonstrated that VSMCs and ECs from individuals who were homozygous for the adenine (A) allele (encoding the Ser214 isoform) had increased migratory ability compared with cells from individuals who were homozygous for the G allele (encoding the Pro214 isoform). Western blot analyses revealed that media conditioned by VSMCs of the A/A genotype contained more cleaved ADAMTS-7 pro-domain and more of the cleaved form of thrombospondin-5 (TSP-5, an ADAMTS-7 substrate that had been shown to be produced by VSMCs and inhibit VSMC migration). In in vitro angiogenesis assays, ECs of the A/A genotype exhibited increased capillary-like network formation. ADAMTS-7 over-expression in ECs by transfection of an ADAMTS7-214Ser expressing plasmid significantly accelerated EC migration and in vitro angiogenesis, whereas ADAMTS-7 knockdown by shRNA had opposite effects. Preliminary proteomics analyses of conditioned media of ECs overexpressing ADAMTS-7 and ECs with ADAMTS-7 knockdown indicated that ADAMTS- 7 can cleave thrombospondin-1 (TSP-1), a well-recognised angiogenesis inhibitor. Conclusion: The results of this study indicate that rs3825807 has a functional effect on ADAMTS-7 maturation, TSP-5 cleavage, VSMC and EC migration, and angiogenesis. As VSMC migration and angiogenesis play important roles in atherosclerosis, these results provide a mechanistic explanation for the association between rs3825807 and CAD.