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Legocki AT, Davis JA, Francis CE. Anisocoria Due to Ocular Ischemic Syndrome. J Neuroophthalmol 2023; 43:e251-e252. [PMID: 35421029 DOI: 10.1097/wno.0000000000001539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Alex T Legocki
- Department of Ophthalmology (ATL, JAD, CEF), University of Washington, Seattle, Washington; and Department of Neurological Surgery (CEF), University of Washington, Seattle, Washington
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Shaffer J, Rajesh A, Stewart MW, Lee AY, Miller DD, Lee CS, Francis CE. Evaluating Access to Laser Eye Surgery by Driving Times Using Medicare Data and Geographical Mapping. JAMA Ophthalmol 2023; 141:776-783. [PMID: 37471084 PMCID: PMC10360006 DOI: 10.1001/jamaophthalmol.2023.3061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 07/21/2023]
Abstract
Importance Recently, several states have granted optometrists privileges to perform select laser procedures (laser peripheral iridotomy, selective laser trabeculoplasty, and YAG laser capsulotomy) with the aim of increasing access. However, whether these changes are associated with increased access to these procedures among each state's Medicare population has not been evaluated. Objective To compare patient access to laser surgery eye care by estimated travel time and 30-minute proximity to an optometrist or ophthalmologist. Design, Setting, and Participants This retrospective cohort database study used Medicare Part B claims data from 2016 through 2020 for patients accessing new patient or laser eye care (laser peripheral iridotomy, selective laser trabeculoplasty, YAG) from optometrists or ophthalmologists in Oklahoma, Kentucky, Louisiana, Arkansas, and Missouri. Analysis took place between December 2021 and March 2023. Main Outcome and Measures Percentage of each state's Medicare population within a 30-minute travel time (isochrone) of an optometrist or ophthalmologist based on US census block group population and estimated travel time from patient to health care professional. Results The analytic cohort consisted of 1 564 307 individual claims. Isochrones show that optometrists performing laser eye surgery cover a geographic area similar to that covered by ophthalmologists. Less than 5% of the population had only optometrists (no ophthalmologists) within a 30-minute drive in every state except for Oklahoma for YAG (301 470 [7.6%]) and selective laser trabeculoplasty (371 097 [9.4%]). Patients had a longer travel time to receive all laser procedures from optometrists than ophthalmologists in Kentucky: the shortest median (IQR) drive time for an optometrist-performed procedure was 49.0 (18.4-71.7) minutes for YAG, and the the longest median (IQR) drive time for an ophthalmologist-performed procedure was 22.8 (12.1-41.4) minutes, also for YAG. The median (IQR) driving time for YAG in Oklahoma was 26.6 (12.2-56.9) for optometrists vs 22.0 (11.2-40.8) minutes for ophthalmologists, and in Arkansas it was 90.0 (16.2-93.2) for optometrists vs 26.5 (11.8-51.6) minutes for ophthalmologists. In Louisiana, the longest median (IQR) travel time to receive laser procedures from optometrists was for YAG at 18.5 (7.6-32.6) minutes and the shortest drive to receive procedures from ophthalmologists was for YAG at 20.5 (11.7-39.7) minutes. Conclusions and Relevance Although this study did not assess impact on quality of care, expansion of laser eye surgery privileges to optometrists was not found to lead to shorter travel times to receive care or to a meaningful increase in the percentage of the population with nearby health care professionals.
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Affiliation(s)
- Jamie Shaffer
- Department of Ophthalmology, University of Washington, Seattle
- Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
| | - Anand Rajesh
- Department of Ophthalmology, University of Washington, Seattle
- Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
| | | | - Aaron Y. Lee
- Department of Ophthalmology, University of Washington, Seattle
- Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
| | - Darby D. Miller
- Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
| | - Cecilia S. Lee
- Department of Ophthalmology, University of Washington, Seattle
- Roger and Angie Karalis Johnson Retina Center, Seattle, Washington
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Subramanian PS, Barton JJS, Ranalli P, Smith C, Francis CE, Frishberg B. Consensus Statement on Visual Rehabilitation in Mild Traumatic Brain Injury. Neurol Clin Pract 2022; 12:422-428. [DOI: 10.1212/cpj.0000000000200071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/20/2022] [Indexed: 11/15/2022]
Abstract
AbstractOptometric visual rehabilitation therapy has been employed for a variety of visual disorders. Descriptively-named entities such as post trauma visual syndrome (PTVS), visual midline shift syndrome (VMSS), and vertical heterophoria syndrome (VHS) are frequently diagnosed by neuro-optometrists and/or behavioral optometrist in patients after stroke or head injury or in the setting of dizziness and/or headache. The scientific underpinnings of these diagnoses and treatments are weak, and published clinical studies comprise case reports and case series without comparison to control populations. Neuro-ophthalmologists are frequently questioned by patients about the utility of such treatment strategies. Many ophthalmologists and neurologists also are involved in the care of patients who carry these diagnoses and undergo these visual therapies. Involved physicians may benefit from guidance about the rationale, evidence, and level of evidence for the efficacy of these therapeutic approaches.
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Figuracion KCF, Halasz LM, Lam NY, Goldberg M, Stuckey J, Failor RA, Knowles LM, Artherholt S, Chou B, Francis CE, Knight K, Kaur M, Sadak T, McGranahan T. Surveillance of long-term complications after treatment of adult brain tumor survivors—review and evidence-based recommendations. Neurooncol Pract 2022; 9:475-486. [DOI: 10.1093/nop/npac053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
AbstractAs a result of treatment and diagnosis, adults with primary or metastatic brain tumors experience comorbidities that impacts their health and well-being. The Children’s Oncology Group has guideline recommendations for childhood survivors of brain tumors; however, guidelines for monitoring long-term sequela among adult brain tumor survivors are lacking. The purpose of this review is to present the screening recommendations for the long-term complications after brain tumor treatment from a multidisciplinary panel of healthcare professionals. Chronic complications identified include cognitive dysfunction, vasculopathy, endocrinopathy, ophthalmic, ototoxicity, physical disability, sleep disturbance, mood disorder, unemployment, financial toxicity, and secondary malignancy. We invited specialists across disciplines to perform a literature search and provide expert recommendations for surveillance for long-term complications for adult brain tumor survivors. The Brain Tumor Center Survivorship Committee recommends routine screening using laboratory testing, subjective assessment of symptoms, and objective evaluations to appropriately monitor the complications of brain tumor treatments. Effective monitoring and treatment should involve collaboration with primary care providers and may require referral to other specialties and support services to provide patient-centered care during neuro-oncology survivorship. Further research is necessary to document the incidence and prevalence of medical complications as well as evaluate the efficacy of screening and neuro-oncology survivorship programs.
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Affiliation(s)
- Karl Cristie F Figuracion
- ITHS TL1 Training Program University of Washington School of Nursing , Seattle, Washington 98105 , USA
- Alvord Brain Tumor Center, Department of Radiation Oncology, University of Washington , Seattle, Washington 98105 , USA
| | - Lia M Halasz
- Department of Radiation Oncology, School of Medicine, University of Washington , Seattle, Washington 98105 , USA
| | - Ny-Ying Lam
- Department of Rehabilitation Medicine, School of Medicine, University of Washington , Seattle, Washington 98105 , USA
| | - Myron Goldberg
- Department of Rehabilitation Medicine, School of Medicine, University of Washington , Seattle, Washington 98105 , USA
| | - Joe Stuckey
- Department of Rehabilitation Medicine, School of Medicine, 98105 University of Washington , Seattle, Washington 98105 , USA
| | - Richard A Failor
- Department of Metabolism, Endocrinology and Nutrition, University of Washington , Seattle, Washington, 98105 , USA
| | - Lindsey M Knowles
- Department of Rehabilitation Medicine, University of Washington , Seattle, Washington 98105 , USA
| | - Samantha Artherholt
- Department of Rehabilitation Medicine, University of Washington , Seattle, Washington 98105 , USA
| | - Brian Chou
- Department of Ophthalmology, School of Medicine, University of Washington , Seattle, Washington 98105 , USA
| | - Courtney E Francis
- Department of Ophthalmology, School of Medicine, University of Washington , Seattle, Washington 98105 , USA
| | - Kristin Knight
- Oregon Health and Science University , Portland, Oregon 97239 , USA
| | - Maninder Kaur
- Loma Linda University Health , Loma Linda, California , USA
| | - Tatiana Sadak
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington , Seattle, Washington 98105 , USA
| | - Tresa McGranahan
- Department of Neurology, School of Medicine, University of Washington , Seattle, Washington 98105 , USA
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Hwang PH, Longstreth WT, Thielke SM, Francis CE, Carone M, Kuller LH, Fitzpatrick AL. Longitudinal Changes in Hearing and Visual Impairments and Risk of Dementia in Older Adults in the United States. JAMA Netw Open 2022; 5:e2210734. [PMID: 35511175 PMCID: PMC9073563 DOI: 10.1001/jamanetworkopen.2022.10734] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Hearing and vision problems are individually associated with increased dementia risk, but the impact of having concurrent hearing and vision deficits, ie, dual sensory impairment (DSI), on risk of dementia, including its major subtypes Alzheimer disease (AD) and vascular dementia (VaD), is not well known. OBJECTIVE To evaluate whether DSI is associated with incident dementia in older adults. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study from the Cardiovascular Health Study (CHS) was conducted between 1992 and 1999, with as many as 8 years of follow-up. The multicenter, population-based sample was recruited from Medicare eligibility files in 4 US communities with academic medical centers. Of 5888 participants aged 65 years and older in CHS, 3602 underwent cranial magnetic resonance imaging and completed the modified Mini-Mental State Examination in 1992 to 1994 as part of the CHS Cognition Study. A total of 227 participants were excluded due to prevalent dementia, leaving a total of 3375 participants without dementia at study baseline. The study hypothesis was that DSI would be associated with increased risk of dementia compared with no sensory impairment. The association between the duration of DSI with risk of dementia was also evaluated. Data analysis was conducted from November 2019 to February 2020. EXPOSURES Hearing and vision impairments were collected via self-report at baseline and as many as 5 follow-up visits. MAIN OUTCOMES AND MEASURES All-cause dementia, AD, and VaD, classified by a multidisciplinary committee using standardized criteria. RESULTS A total of 2927 participants with information on hearing and vision at all available study visits were included in the analysis (mean [SD] age, 74.6 [4.8] years; 1704 [58.2%] women; 455 [15.5%] African American or Black; 2472 [85.5%] White). Compared with no sensory impairment, DSI was associated with increased risk of all-cause dementia (hazard ratio [HR], 2.60; 95% CI, 1.66-2.06; P < .001), AD (HR, 3.67; 95% CI, 2.04-6.60; P < .001) but not VaD (HR, 2.03; 95% CI, 1.00-4.09; P = .05). CONCLUSIONS AND RELEVANCE In this cohort study, DSI was associated with increased risk of dementia, particularly AD. Evaluation of hearing and vision in older adults may help to identify those at high risk of developing dementia.
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Affiliation(s)
- Phillip H Hwang
- Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston, Massachusetts
| | - W T Longstreth
- Department of Epidemiology, University of Washington, Seattle
- Department of Neurology, University of Washington, Seattle
| | - Stephen M Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
- Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, Washington
| | | | - Marco Carone
- Department of Biostatistics, University of Washington, Seattle
| | - Lewis H Kuller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Annette L Fitzpatrick
- Department of Epidemiology, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
- Department of Family Medicine, University of Washington, Seattle
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Froines CP, Van Brummen AJ, Francis CE. A Case of Isolated Bilateral Trochlear Nerve Schwannomas. J Neuroophthalmol 2022; 42:e394-e395. [PMID: 34348363 DOI: 10.1097/wno.0000000000001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Colin P Froines
- Departments of Ophthalmology (CPF, AJV, CEF) and Neurological Surgery (CEF), University of Washington School of Medicine, Seattle, Washington
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Abstract
BACKGROUND The number of ophthalmology-trained residents applying to neuro-ophthalmology fellowships has not increased despite a trend toward seeking fellowship training after residency. This study sought to identify factors affecting the choice to pursue or not pursue neuro-ophthalmology fellowship training by graduating ophthalmology residents and recently graduated neuro-ophthalmology fellows. METHODS An anonymous survey was sent to Association of University Professors of Ophthalmology residency directors to distribute to post-graduate Year 4 (PGY4) ophthalmology residents graduating in either 2018 or 2019. A second anonymous survey was distributed via the North American Neuro-Ophthalmology Society (NANOS) Young Neuro-Ophthalmologists listserv to ophthalmology-trained neuro-ophthalmology fellows. A total of 147 respondents, including 96 PGY4 ophthalmology residents not going into neuro-ophthalmology and 51 practicing neuro-ophthalmologists are included. RESULTS The most common reasons for residents to choose to not pursue further training in neuro-ophthalmology included a stronger interest in other fields, types of patients seen, no intraocular surgery, and the assumption that it is a nonsurgical discipline. The leading factors influencing graduated, ophthalmology-trained fellows to choose neuro-ophthalmology included interest in the clinical diseases treated, interaction with other specialty fields, and a supportive NANOS culture. Interestingly, despite perceptions of graduating residents, two-thirds of the neuro-ophthalmologists surveyed perform surgery. There were no differences between the 2 groups with respect to the degree of exposure to neuro-ophthalmology in medical school, presence of a dedicated neuro-ophthalmology rotation in residency, or timing of the rotation. CONCLUSIONS There are a variety of factors influencing decisions regarding pursuing neuro-ophthalmology fellowship among ophthalmology residents. The perceived lack of surgical opportunities in neuro-ophthalmology is a deterrent for many. However, a significant number of neuro-ophthalmologists continue to perform surgery, including intraocular surgery. Repeated exposure later in residency may provide an opportunity to reconsider the field and to re-emphasize opportunities to remain surgically involved as a neuro-ophthalmologist. Exposure to the practice patterns of recently graduated neuro-ophthalmologists offers residents in training excellent exposure to the contemporary practice of neuro-ophthalmology. Hence, ensuring trainees receive a balanced exposure to practicing neuro-ophthalmologists across the spectrum of seniority and scope of practice may promote greater interest among ophthalmology residents to pursue a career in neuro-ophthalmology.
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Affiliation(s)
- Alexander M Solomon
- Department of Ophthalmology (AMS, CEF), University of Washington School of Medicine, Seattle, Washington; USC Roski Eye Institute (VRP), Keck School of Medicine of the University of Southern California, Los Angeles, California; and Department of Neurological Surgery (CEF), University of Washington School of Medicine, Seattle, Washington
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Chou BW, Rivera QN, Francis CE. Spontaneous retrobulbar hemorrhage in the setting of warfarin therapy and latent scurvy diagnosis. Orbit 2021; 41:127-129. [PMID: 34913816 DOI: 10.1080/01676830.2021.2012204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We present a case of spontaneous nontraumatic retrobulbar hemorrhage associated with anti-coagulation therapy and a new diagnosis of scurvy. A 68-year-old male on chronic anti-coagulation therapy presented with a retrobulbar hemorrhage requiring urgent canthotomy and cantholysis. Despite the absence of a supratherapeutic INR and normal clotting factors, the patient continued to have spontaneous hemorrhages within the orbit and elsewhere. Workup revealed a severe vitamin C deficiency consistent with scurvy. Further investigation of dietary history demonstrated an avoidance of all citrus fruit upon starting warfarin due to misunderstanding in medication counseling on avoidance of grapefruit. With repletion of vitamin C and further medication counseling, the patient had no further episodes of spontaneous hemorrhage.
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Affiliation(s)
- Brian W Chou
- Department of Ophthalmology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Quinn N Rivera
- Department of Ophthalmology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Courtney E Francis
- Department of Ophthalmology, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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Hwang PH, Longstreth W, Thielke S, Francis CE, Carone M, Kuller LH, Fitzpatrick AL. Longitudinal changes in hearing and visual impairments associated with risk of dementia in older adults: The Cardiovascular Health Study. Alzheimers Dement 2021. [DOI: 10.1002/alz.049110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Stephen Thielke
- University of Washington Seattle WA USA
- VAPSHCS/GRECC Seattle WA USA
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Solomon AM, Chia TMT, Juric-Sekhar G, Francis CE. BRAF V600E-Mutated Ganglioglioma of the Optic Pathway: A Case Report and Review of the Literature. J Neuroophthalmol 2021; 41:e723-e727. [PMID: 33394641 DOI: 10.1097/wno.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Alexander M Solomon
- Department of Ophthalmology (AMS, CEF), University of Washington School of Medicine, Seattle, Washington; Department of Ophthalmology (TMTC), Southern California Permanente Medical Group, Kern County, California; and Departments of Pathology (GJ-S), and Neurological Surgery (GJ-S, CEF), University of Washington School of Medicine, Seattle, Washington
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11
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Van Gelder RN, Wu Y, Taravati P, Yanagihara RT, Francis CE, Blazes M, Lee CS, Lee AY. Inefficiencies in Residency Matching Associated with Gale–Shapley Algorithms. Journal of Academic Ophthalmology 2021. [DOI: 10.1055/s-0041-1735951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Objective This study aimed to investigate emerging trends and increasing costs in the National Residency Matching Program (NRMP) and San Francisco Residency and Fellowship Match Services (SF Match) associated with the current applicant/program Gale–Shapley-type matching algorithms.
Design A longitudinal observational study of behavioral trends in national residency matching systems with modeling of match results with alternative parameters.
Patients and Methods We analyzed publicly available data from the SF Match and NRMP websites from 1985 to 2020 for trends in the total number of applicants and available positions, as well the average number of applications and interviews per applicant for multiple specialties. To understand these trends and the algorithms' effect on the residency programs and applicants, we analyzed anonymized rank list and match data for ophthalmology from the SF Match between 2011 and 2019. Match results using current match parameters, as well as under conditions in which applicant and/or program rank lists were truncated with finalized rank lists, were analyzed.
Results Both the number of applications and length of programs' rank lists have increased steadily throughout residency programs, particularly those with competitive specialties. Capping student rank lists at seven programs, or less than 80% of the average 8.9 programs currently ranked, results in a 0.71% decrease in the total number of positions filled. Similarly, capping program rank lists at seven applicants per spot, or less than 60% of the average 11.5 applicants ranked per spot, results in a 5% decrease in the total number of positions filled.
Conclusion While the number of ophthalmology positions in the United States has increased only modestly, the number of applications under consideration has increased substantially over the past two decades. The current study suggests that both programs and applicants rank more choices than are required for a nearly complete and stable match, creating excess cost and work for both applicants and programs. “Stable-marriage” type algorithms induce applicants and programs to rank as many counterparties as possible to maximize individual chances of optimizing the match.
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Affiliation(s)
| | - Yue Wu
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Parisa Taravati
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Ryan T. Yanagihara
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | | | - Marian Blazes
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Cecilia S. Lee
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Aaron Y. Lee
- Department of Ophthalmology, University of Washington, Seattle, Washington
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Hwang PH, Longstreth W, Thielke SM, Francis CE, Carone M, Kuller LH, Fitzpatrick AL. Ophthalmic conditions associated with dementia risk: The Cardiovascular Health Study. Alzheimers Dement 2021; 17:1442-1451. [PMID: 33788406 PMCID: PMC8527838 DOI: 10.1002/alz.12313] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ophthalmic conditions and dementia appear to overlap and may share common pathways, but research has not differentiated dementia subtypes. METHODS Diagnoses of cataracts, age-related macular degeneration (AMD), diabetic retinopathy (DR), and glaucoma were based on medical histories and International Classification of Diseases, Ninth Revision (ICD-9) codes for 3375 participants from the Cardiovascular Health Study. Dementia, including Alzheimer's disease (AD) and vascular dementia (VaD), was classified using standardized research criteria. RESULTS Cataracts were associated with AD (hazard ratio [HR] = 1.34; 95% confidence interval [CI] = 1.01-1.80) and VaD/mixed dementia (HR = 1.41; 95% CI = 1.02-1.95). AMD was associated with AD only (HR = 1.87; 95% CI = 1.13-3.09), whereas DR was associated with VaD/mixed dementia only (HR = 2.63; 95% CI = 1.10-6.27). DISCUSSION Differential associations between specific ophthalmic conditions and dementia subtypes may elucidate pathophysiologic pathways. Lack of association between glaucoma and dementia was most surprising from these analyses.
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Affiliation(s)
- Phillip H. Hwang
- Department of Epidemiology, University of Washington, Seattle, WA, USA;,Corresponding author contact information: University of Washington, Department of Epidemiology, 3980 15 Avenue Northeast, Box 351619, Seattle, WA 98195, , Phone: (206) 331-8633
| | - W.T. Longstreth
- Department of Epidemiology, University of Washington, Seattle, WA, USA;,Department of Neurology, University of Washington, Seattle, WA, USA
| | - Stephen M. Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA;,Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, WA, USA
| | | | - Marco Carone
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Lewis H. Kuller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Annette L. Fitzpatrick
- Department of Epidemiology, University of Washington, Seattle, WA, USA;,Department of Global Health, University of Washington, Seattle, WA, USA;,Department of Family Medicine, University of Washington, Seattle, WA, USA
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Hwang PH, Longstreth WT, Thielke S, Francis CE, Carone M, Fitzpatrick AL. Associations between ophthalmic conditions and risk of dementia in older adults. Alzheimers Dement 2020. [DOI: 10.1002/alz.040775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Hwang PH, Longstreth W, Brenowitz WD, Thielke SM, Lopez OL, Francis CE, DeKosky ST, Fitzpatrick AL. Dual sensory impairment in older adults and risk of dementia from the GEM Study. Alzheimers Dement (Amst) 2020; 12:e12054. [PMID: 32671180 PMCID: PMC7340796 DOI: 10.1002/dad2.12054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hearing and vision loss are independently associated with dementia, but the impact of dual sensory impairment (DSI) on dementia risk is not well understood. METHODS Self-reported measures of hearing and vision were taken from 2051 participants at baseline from the Gingko Evaluation of Memory Study. Dementia status was ascertained using standardized criteria. Cox models were used to estimate risk of dementia associated with number of sensory impairments (none, one, or two). RESULTS DSI was significantly associated with higher risk of all-cause dementia (hazard ratio [HR] = 1.86; 95% confidence interval [CI] = 1.25-2.76) and Alzheimer's disease (HR = 2.12; 95% CI = 1.34-3.36). Individually only visual impairment was independently associated with an increased risk of all-cause dementia (HR = 1.32; 95% CI = 1.02-1.71). DISCUSSION Older adults with DSI are at a significantly increased risk for dementia. Further studies are needed to evaluate whether treatments can modify this risk.
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Affiliation(s)
- Phillip H. Hwang
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - W.T. Longstreth
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of NeurologyUniversity of WashingtonSeattleWashingtonUSA
| | - Willa D. Brenowitz
- Department of PsychiatryUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Stephen M. Thielke
- Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleWashingtonUSA
- Geriatric ResearchEducationand Clinical CenterPuget Sound VA Medical CenterSeattleWashingtonUSA
| | - Oscar L. Lopez
- Department of NeurologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Department of PsychiatryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | | | | | - Annette L. Fitzpatrick
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Family MedicineUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
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Liu KC, Bhatti MT, Chen JJ, Fairbanks AM, Foroozan R, McClelland CM, Lee MS, Satija CE, Francis CE, Wildes MT, Subramanian PS, Williams ZR, El-Dairi MA. Presentation and Progression of Papilledema in Cerebral Venous Sinus Thrombosis. Am J Ophthalmol 2020; 213:1-8. [PMID: 31926886 DOI: 10.1016/j.ajo.2019.12.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the natural history and visual outcomes of papilledema in cerebral venous sinus thrombosis (CVST). DESIGN Retrospective observational case series. METHODS This multicenter study included 7 tertiary care neuro-ophthalmology clinics. Sixty-five patients with CVST were identified who received serial eye examinations with documented papilledema from 2008-2016. Outcome measures included time from diagnosis to papilledema documentation, papilledema progression, time to papilledema resolution, treatment interventions and final visual outcomes. RESULTS Papilledema was present on initial presentation in 54% of patients or detected later during the course of the disease in 46% of patients. The average time from CVST diagnosis to papilledema documentation was 29 days with a mean (SD) initial Frisén grade of 2.7 (1.3). In 21.5% of cases, papilledema progressed over an average of 55.6 (56.6) days. Time to papilledema resolution was approximately 6 months. Final visual acuity ranged from 20/20 to light perception, with 40% of patients having residual visual field defects on standard automated perimetry. Frisén grade ≥3 (odds ratio [OR] 10.21, P < .0053) and cases with worsening papilledema (3.5, P < .043) were associated with permanent visual field deficits. CONCLUSIONS Our study indicates the importance of serial ophthalmic evaluation in all cases of CVST. Follow-up fundoscopy is critical given that a subset of cases can show delayed onset and/or worsening of papilledema with time. Specifically, we recommend an ophthalmic examination at the time of initial diagnosis, with repeat examination within a few weeks and further follow-up depending on the level of papilledema or vision changes.
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Hwang PH, Longstreth WT, Francis CE, Thielke S, Fitzpatrick AL. DUAL SENSORY IMPAIRMENT IN OLDER ADULTS AND RISK OF DEMENTIA AND ALZHEIMER'S DISEASE. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.4527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Abstract
This report describes a solitary orbital metastasis of lobular carcinoma in a woman 35 years after diagnosis of right breast lobular carcinoma in situ (LCIS). After partial response to anastrozole, the patient was treated with proton radiotherapy to 45 cobalt gray equivalents (CGE) with an excellent response. We additionally discuss treatment strategies for this rare metastatic site.
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Affiliation(s)
- Matthew B Spraker
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | | | - Larissa Korde
- Divison of Oncology, University of Washington, Seattle, WA
| | - Janice Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Lia Halasz
- Department of Radiation Oncology, University of Washington, Seattle, Wa
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McInnis CP, Haynor DR, Francis CE. Horner syndrome in fibromuscular dysplasia without carotid dissection. Can J Ophthalmol 2016; 51:e53-5. [PMID: 27085276 DOI: 10.1016/j.jcjo.2015.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 10/08/2015] [Accepted: 10/28/2015] [Indexed: 11/19/2022]
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20
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Sychev YV, McInnis CP, Francis CE. Abducens ocular neuromyotonia as a delayed complication of oropharyngeal carcinoma treated with radiation. Head Neck 2016; 38 Suppl 1:E2428-31. [PMID: 26836222 DOI: 10.1002/hed.24370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 10/14/2015] [Accepted: 11/25/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Ocular neuromyotonia (ONM) is a disorder characterized by periodic involuntary extraocular muscle contraction that occurs almost exclusively in the setting of prior radiation to the sella or skull base. We present the first case of abducens neuromyotonia associated with oropharyngeal carcinoma. METHODS AND RESULTS We report a case of a 63-year-old patient with abducens ONM occurring 16 years after radiation treatment for oropharyngeal squamous cell carcinoma. A literature review was performed using Medline and PubMed databases to search for all documented cases of abducens neuromyotonia. Our review found 20 cases of abducens neuromyotonia but none after radiotherapy (RT) to the oropharynx. CONCLUSION Abducens ONM can occur because of disease at anatomic locations remote from the course of the sixth cranial nerve, most likely because of the irradiated area exceeding the intended field. Our case also supports the fact that RT can significantly precede symptom onset. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2428-E2431, 2016.
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Affiliation(s)
- Yevgeniy V Sychev
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Colin P McInnis
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Courtney E Francis
- Department of Ophthalmology, University of Washington, Seattle, Washington
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21
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Abstract
Hypotony maculopathy is a condition that may result in visual deterioration from choroidal folds or optic disc edema. Optic disc edema can result from altered translaminar pressure gradients (lowered intraocular pressure, increased cerebrospinal fluid pressure, or increased orbital pressure). We report a case of bilateral optic disc edema in a patient with glaucoma and thyroid-related orbitopathy. The patient's disc edema was initially presumed to be secondary to her orbitopathy, but persisted after bilateral orbital decompression. Ultimately, disc edema and choroidal folds in the right eye resolved after trabeculectomy revision and an increase in intraocular pressure. This case serves as a reminder of the causes of optic disc edema and demonstrates delayed reversal of hypotony maculopathy.
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Affiliation(s)
- Divakar Gupta
- Department of Ophthalmology, University of Washington, Seattle, Wash., USA
| | - Mark Slabaugh
- Department of Ophthalmology and Visual Science, The Ohio State University, Columbus, Ohio, USA
| | - Courtney E Francis
- Department of Ophthalmology, University of Washington, Seattle, Wash., USA
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22
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Abstract
Multiple sclerosis has several ophthalmic manifestations, including optic neuritis, internuclear ophthalmoplegia, and nystagmus. The presentation, treatment, and prognosis of visual complaints secondary to multiple sclerosis are discussed. Additionally, the use of optical coherence tomography and complications related to the use of fingolimod are considered.
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Affiliation(s)
- Courtney E Francis
- Department of Ophthalmology, University of Washington, Box 359608, 325 9th Avenue, Seattle, WA 98104-2499, USA.
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Yaar R, Cataldo LM, Tzatsos A, Francis CE, Zhao Z, Ravid K. Regulation of the A3 adenosine receptor gene in vascular smooth muscle cells: role of a cAMP and GATA element. Mol Pharmacol 2002; 62:1167-76. [PMID: 12391281 DOI: 10.1124/mol.62.5.1167] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In previous studies, we reported that the level of expression of the adenylyl cyclase inhibitory A3 adenosine receptor (AR) impacts vascular tone and that rat vascular smooth muscle cells (VSMCs) coexpress the A3 AR and the adenylyl cyclase stimulatory A2a- and A2b-type ARs. In the current study, we investigated the regulation of expression of the A3 AR gene, focusing on sequences conserved in the mouse and human promoters. Transient transfection of primary cultures of rat VSMCs, using the mouse A3 AR promoter, shows that mutation of a conserved cAMP response element (CRE) significantly up-regulates promoter activity in first passage cells, whereas mutation of a conserved GATA site reduces promoter activity. This suggests that an inhibitory protein binds the CRE, whereas an enhancing factor binds the GATA sequence. Electrophoretic mobility shift assays (EMSAs) indicate that the putative CRE and GATA sites indeed bind cAMP response element modulator 1/c-Jun and the GATA6 protein, respectively. A3 AR promoter activity is significantly up-regulated in the presence of forskolin, the nonselective agonist 5'-(N-ethylcarboxamido)adenosine, or the A2a AR agonist 4-[2-[[6-amino-9(N-ethyl-beta-D-ribofuranuronamidosyl)-9H-purin-2-yl]amino]ethyl]benzenepro- panoic acid (CGS21680), reaching levels similar to those of the A3 AR promoter bearing a mutated CRE. EMSA indicates that in the presence of forskolin the binding to the CRE is inhibited, suggesting that cAMP elevation disturbs the formation of an inhibitory complex on the CRE. Finally, semiquantitative reverse transcription-polymerase chain reaction analysis reveals that endogenous A3 AR mRNA is elevated in response to forskolin. Our findings suggest the presence of a mechanism by which cAMP might control its own level in cells via regulation of genes involved in modulation of adenylyl cyclase activity.
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Affiliation(s)
- R Yaar
- Department of Biochemistry and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts 02118, USA
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Zhao Z, Makaritsis K, Francis CE, Gavras H, Ravid K. A role for the A3 adenosine receptor in determining tissue levels of cAMP and blood pressure: studies in knock-out mice. Biochim Biophys Acta 2000; 1500:280-90. [PMID: 10699369 DOI: 10.1016/s0925-4439(99)00111-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Adenosine administration has been reported to lower blood pressure by activating specific membrane receptors. The rat and human heart and aorta have been previously found to express both A2-type adenosine receptors, which activate adenylyl cyclase, and A3 adenosine receptors (A3AR), which inhibit adenylyl cyclase. In the current study, we used A3 adenosine receptor (A3AR) knock-out mice to examine the hypothesis that the relative levels of the A2-type adenosine receptors and A3AR determine the steady-state levels of cAMP in the cells and may affect blood pressure. We found that the A3AR knock-out mice express normal levels of the A1- and A2-type adenosine receptors. In situ hybridization demonstrated that the level of A3AR is high in the vascular smooth muscle layer of aortas derived from wild-type mice, but is not detectable in the knock-out mice. The steady-state level of cAMP is elevated in the aorta and heart of knock-out mice, as compared to wild-type mice, but is not altered in platelets, where A3AR is not expressed naturally. A3AR knock-out mice possess a blood pressure comparable to this in wild-type mice. However, when challenged with adenosine, the knock-out mice display a further increase in cAMP levels in the heart and vascular smooth muscle and a significant decrease in blood pressure, as compared to wild-type mice. In contrast, the effect of adenosine on ADP-induced platelet aggregation is similar in both types of mice. These studies indicate that the A3AR affects the steady-state level of cAMP in the tissues where it is naturally expressed, and that it influences the blood pressure in response to adenosine.
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Affiliation(s)
- Z Zhao
- Department of Biochemistry and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA 02118, USA
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Zhao Z, Francis CE, Welch G, Loscalzo J, Ravid K. Reduced glutathione prevents nitric oxide-induced apoptosis in vascular smooth muscle cells. Biochim Biophys Acta 1997; 1359:143-52. [PMID: 9409811 DOI: 10.1016/s0167-4889(97)00093-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The control of medial and neointimal growth, in which vascular smooth muscle (VSM) plays a central role, is most important to the development of hypertension and atherosclerosis, respectively. Growth of vascular smooth muscle cells is regulated by a number of factors, including the vasodilator nitric oxide (NO). In addition, NO modulates intracellular thiol redox states and the thiol redox state of the cell influences NO production. We, therefore, examined the nature of the effect of NO on growth of VSM cells and its modulation by cellular glutathione content. Here, we report that NO, either generated by NO donors or synthesized by iNOS in VSM cells, inhibited DNA synthesis and induced apoptosis in this cell type. NO-induced apoptosis was associated with a significant decrease in the intracellular concentration of reduced glutathione and with an increase in the level of the tumor suppressor gene p53 mRNA. Moreover, addition of glutathione monoethylester to the culture restored the level of reduced glutathione in VSM cells, and prevented the NO-induced increase in p53 expression and programmed cell death. Our findings suggest a role for reduced glutathione in protecting VSM cells exposed to NO from apoptosis.
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MESH Headings
- Animals
- Apoptosis/drug effects
- Cell Division/drug effects
- Cells, Cultured
- Flow Cytometry
- Genes, myc
- Genes, p53/genetics
- Glutathione/analogs & derivatives
- Glutathione/metabolism
- Glutathione/pharmacology
- Lipopolysaccharides/pharmacology
- Microscopy, Fluorescence
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/drug effects
- Nitric Oxide/pharmacology
- Nitric Oxide/physiology
- Nitroprusside/pharmacology
- Nitroso Compounds/pharmacology
- RNA, Messenger/analysis
- Rats
- Rats, Sprague-Dawley
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Affiliation(s)
- Z Zhao
- Department of Biochemistry, Boston University School of Medicine, MA 02118, USA
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Zhao Z, Francis CE, Ravid K. An A3-subtype adenosine receptor is highly expressed in rat vascular smooth muscle cells: its role in attenuating adenosine-induced increase in cAMP. Microvasc Res 1997; 54:243-52. [PMID: 9441895 DOI: 10.1006/mvre.1997.2044] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Adenosine analogs are known to induce changes in the steady-state concentration of cAMP via binding to adenylyl cyclase-inhibitory or -stimulatory adenosine receptors. Although adenosine has been found to increase cAMP in vascular smooth muscle cells (VSMC), we found by the polymerase chain reaction of reverse-transcribed RNA and subsequently by Northern blot analysis that rat VSMC express high levels of an A3-subtype adenosine receptor cDNA which encodes an adenylyl cyclase-inhibitory adenosine receptor. The A3-specific agonist, N6-(3-iodobenzyl) adenosine-5'-N-mehylcarboxamide (IB-MECA) indeed decreases cAMP levels in VSMC cultured in the presence of forskolin. Antisense oligomers to the A3 adenosine receptor significantly reduce the level of this receptor in VSMC and potentiate endogenous adenosine- or 5'-N-ethylcarboxamido adenosine-induced increases in cAMP and of the proto-oncogene c-fos. Abrogating the expression of the A3 adenosine receptor also largely abolishes IB-MECA-induced inhibition of adenylyl cyclase. The level of A3 adenosine receptor mRNA and the extent of changes in cAMP in response to IB-MECA were lower in cultures of VSMC derived from adult rats, compared to VSMC from neonatal rats. The expression of a functional A3 adenosine receptor was also confirmed in preparations of isolated aortas. Our findings thus indicate that: (a) the A3-type receptor is a functional inhibitory adenosine receptor in VSMC; and (b) the regulation of expression of the A3 receptor is critical in determining effects of adenosine on the steady-state concentration of cAMP.
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MESH Headings
- Adenosine/pharmacology
- Adenosine/physiology
- Adenosine-5'-(N-ethylcarboxamide)/pharmacology
- Adenylyl Cyclase Inhibitors
- Adenylyl Cyclases/metabolism
- Animals
- Aorta/metabolism
- Blotting, Northern
- Cyclic AMP/metabolism
- Gene Expression Regulation/drug effects
- Genes, fos/drug effects
- Intracellular Fluid/metabolism
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/physiology
- Oligonucleotides, Antisense/pharmacology
- Organ Specificity
- RNA, Messenger/analysis
- Rats
- Rats, Sprague-Dawley
- Receptors, Purinergic P1/biosynthesis
- Receptors, Purinergic P1/genetics
- Receptors, Purinergic P1/physiology
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Affiliation(s)
- Z Zhao
- Department of Biochemistry and Whitaker Cardiovascular Institute, Boston University School of Medicine, Massachusetts 02139, USA
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Francis CE. Soft Foils and Plastic Stoppings. Int Dent J (Phila) 1894; 15:356-362. [PMID: 37911639 PMCID: PMC10114835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
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Francis CE. Professional Courtesies in Connection with What Are Commonly Considered Failures in Dental Practice: Read before the New Jersey State Dental Society. Indep Pract 1886; 7:538-541. [PMID: 37826457 PMCID: PMC10085141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. About Cocaine. Indep Pract 1886; 7:356-358. [PMID: 37826437 PMCID: PMC10085115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. Anticipating Caries. Indep Pract 1885; 6:574-577. [PMID: 37826312 PMCID: PMC10075865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. Mirabile. Indep Pract 1885; 6:75-76. [PMID: 37826297 PMCID: PMC10075845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. Rough Enamel. Indep Pract 1885; 6:20-21. [PMID: 37826220 PMCID: PMC10075749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. Incident of Practice. Indep Pract 1884; 5:253. [PMID: 37825748 PMCID: PMC10065504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. An Incident of Practice. Indep Pract 1884; 5:142-143. [PMID: 37825731 PMCID: PMC10065480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. Keeping the Teeth Clean. Indep Pract 1883; 4:204-206. [PMID: 37826172 PMCID: PMC10072741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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Francis CE. An Incident of Practice. Indep Pract 1882; 3:567-568. [PMID: 37825422 PMCID: PMC10062733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
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