Application of a user experience design approach for an EHR-based clinical decision support system

Objective

We applied a user experience (UX) design approach to clinical decision support (CDS) tool development for the specific use case of pediatric asthma. Our objective was to understand physicians' workflows, decision-making processes, barriers (ie, pain points), and facilitators to increase usability of the tool.

Materials and methods

We used a mixed-methods approach with semi-structured interviews and surveys. The coded interviews were synthesized into physician-user journey maps (ie, visualization of a process to accomplish goals) and personas (ie, user types). Interviews were conducted via video. We developed physician journey maps and user personas informed by their goals, systems interactions, and experiences with pediatric asthma management.

Results

The physician end-user personas identified were: efficiency, relationship, and learning. Features of a potential asthma CDS tool sought varied by physician practice type and persona. It was important to the physician end-user that the asthma CDS tool demonstrate value by lowering workflow friction (ie, difficulty or obstacles), improving the environment surrounding physicians and patients, and using it as a teaching tool. Customizability versus standardization were important considerations for uptake.

Discussion

Different values and motivations of physicians influence their use and interaction with the EHR and CDS tools. These different perspectives can be captured by applying a UX design approach to the development process. For example, with the importance of customizability, one approach may be to build a core module with variations depending on end-user preference.

Conclusion

A UX approach can drive design to help understand physician-users and meet their needs; ultimately with the goal of increased uptake.

Systematic review and network meta-analysis comparing the efficacy of fezolinetant with hormone and nonhormone therapies for treatment of vasomotor symptoms due to menopause

IMPORTANCE

The neurokinin 3 receptor antagonist fezolinetant 45 mg/d significantly reduced frequency/severity of moderate to severe vasomotor symptoms (VMS) of menopause compared with placebo in two phase 3 randomized controlled trials. Its efficacy relative to available therapies is unknown.

OBJECTIVE

We conducted a systematic review and Bayesian network meta-analysis to compare efficacy with fezolinetant 45 mg and hormone therapy (HT) and non-HT for VMS in postmenopausal women.

EVIDENCE REVIEW

Using OvidSP, we systematically searched multiple databases for phase 3 or 4 randomized controlled trials in postmenopausal women with ≥7 moderate to severe VMS per day or ≥50 VMS per week published/presented in English through June 25, 2021. Mean change in frequency and severity of moderate to severe VMS from baseline to week 12 and proportion of women with ≥75% reduction in VMS frequency at week 12 were assessed using fixed-effect models.

FINDINGS

The network meta-analysis included data from the pooled phase 3 fezolinetant trials plus 23 comparator publications across the outcomes analyzed (frequency, 19 [34 regimens]; severity, 6 [7 regimens]; ≥75% response, 9 [15 regimens]). Changes in VMS frequency did not differ significantly between fezolinetant 45 mg and any of the 27 HT regimens studied. Fezolinetant 45 mg reduced the frequency of moderate to severe VMS events per day significantly more than all non-HTs evaluated: paroxetine 7.5 mg (mean difference [95% credible interval {CrI}], 1.66 [0.63-2.71]), desvenlafaxine 50 to 200 mg (mean differences [95% CrI], 1.12 [0.10-2.13] to 2.16 [0.90-3.40]), and gabapentin ER 1800 mg (mean difference [95% CrI], 1.63 [0.48-2.81]), and significantly more than placebo (mean difference, 2.78 [95% CrI], 1.93-3.62]). Tibolone 2.5 mg (the only HT regimen evaluable for severity) significantly reduced VMS severity compared with fezolinetant 45 mg. Fezolinetant 45 mg significantly reduced VMS severity compared with desvenlafaxine 50 mg and placebo and did not differ significantly from higher desvenlafaxine doses or gabapentin ER 1800 mg. For ≥75% responder rates, fezolinetant 45 mg was less effective than tibolone 2.5 mg (not available in the United States) and conjugated estrogens 0.625 mg/bazedoxifene 20 mg (available only as 0.45 mg/20 mg in the United States), did not differ significantly from other non-HT regimens studied and was superior to desvenlafaxine 50 mg and placebo.

CONCLUSIONS

The only HT regimens that showed significantly greater efficacy than fezolinetant 45 mg on any of the outcomes analyzed are not available in the United States. Fezolinetant 45 mg once daily was statistically significantly more effective than other non-HTs in reducing the frequency of moderate to severe VMS.

RELEVANCE

These findings may inform decision making with regard to the individualized management of bothersome VMS due to menopause.

Cost-Effectiveness Analysis of Pembrolizumab as an Adjuvant Treatment of Renal Cell Carcinoma Post-nephrectomy in the United States

INTRODUCTION

Pembrolizumab was recently approved as an adjuvant treatment of renal cell carcinoma (RCC), based on prolonged disease-free survival compared to placebo in the phase III KEYNOTE-564 trial. The objective of this study was to evaluate the cost-effectiveness of pembrolizumab as monotherapy in the adjuvant treatment of RCC post-nephrectomy, from a US health sector perspective.

PATIENTS AND METHODS

A Markov model with 4 health states (disease-free, locoregional recurrence, distant metastases, and death) was developed to compare the cost and effectiveness of pembrolizumab versus routine surveillance or sunitinib. Transition probabilities were estimated using patient-level KEYNOTE-564 data (cutoff: June 14, 2021), a retrospective study, and published literature. Costs of adjuvant and subsequent treatments, adverse events, disease management, and terminal care were estimated in 2022 US$. Utilities were based on EQ-5D-5L data collected in KEYNOTE-564. Outcomes included costs, life-years (LYs), and quality-adjusted LYs (QALYs). Robustness was assessed through one-way and probabilistic sensitivity analyses.

RESULTS

Total cost per patient was $549,353 for pembrolizumab, $505,094 for routine surveillance, and $602,065 for sunitinib. Over a lifetime, pembrolizumab provided gains of 0.96 QALYs (1.00 LYs) compared to routine surveillance, yielding an incremental cost-effectiveness ratio of $46,327/QALY. Pembrolizumab dominated sunitinib with 0.89 QALYs (0.91 LYs) gained while saving costs. At a $150,000/QALY threshold, pembrolizumab was cost-effective versus both routine surveillance and sunitinib in 84.2% of probabilistic simulations.

CONCLUSION

Pembrolizumab is projected to be cost-effective as an adjuvant RCC treatment versus routine surveillance or sunitinib based on a typical willingness-to-pay threshold.

Real-world effectiveness of omadacycline and impact of unapproved omadacycline prescription claims among adult outpatients with community-acquired bacterial pneumonia or acute bacterial skin and skin structure infections

BACKGROUND: Omadacycline is an amino-methylcycline antibiotic that is indicated for the treatment of adults with community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSI). Like many new antibiotics, there are scant real-world effectiveness data for omadacycline. There is also a high potential that an omadacycline prescription is rejected or reversed, and it is not known whether patients who have an unapproved omadacycline claim are at higher risk for 30-day emergency department (ED)/inpatient (IP) visits. OBJECTIVE: To describe the real-world effectiveness of omadacycline and assess the impact of unapproved omadacycline claims among adult outpatients with CABP or ABSSSIs. METHODS: The study population included patients who received 1 or more omadacycline outpatient prescriptions from a large US claims database (October 2018 to September 2020) and had a diagnosis for CABP or ABSSSI. The approval status of omadacycline claims was determined. The proportion of all-cause 30-day ED/IP visits among patients with an approved vs unapproved claim was compared. RESULTS: 404 patients met the inclusion criteria (CABP: 97; ABSSSI: 307). Of the 404 patients, 146 (36%) had an unapproved claim (CABP: 28; ABSSSI: 118). Overall, the proportion of 30-day ED/IP visits (yes/no) for those with an unapproved and approved claim was 28% vs 17%, respectively (P < 0.05). The overall adjusted 30-day ED/IP visits incidence difference was 11% (95% CI = 2 - 19), corresponding to an adjusted number needed to treat of 9 (95% CI = 5 - 43). CONCLUSIONS: A high incidence (36%) of unapproved omadacydine claims was observed in this study. Patients with unapproved daims had an 11% higher incidence of 30-day all-cause ED/IP visits than patients with approved claims. DISCLOSURES This study was funded by Paratek Pharmaceuticals, Inc (King of Prussia, PA). Dr Lodise is a consultant to Paratek Pharmaceuticals, Inc, and has received consultancy payments. Drs Gunter, Sandor, and Berman are employees and shareholders of Paratek Pharmaceuticals, Inc. Dr Mu, Ms Gao, Ms Yang, and Ms Yim are employees of Analysis Group. Analysis Group has received payment from Paratek Pharmaceuticals, Inc, to conduct part of this study.

A comparison of the Sepsis-2 and Sepsis-3 definitions for assessment of mortality risk in dogs with parvovirus

OBJECTIVE

To evaluate the use of a modified Sepsis-3 (mSepsis-3) definition compared to the currently used modified Sepsis-2 (mSepsis-2) definition to determine whether the mSepsis-2 or mSepsis-3 stratifications were able to identify populations of dogs ultimately more likely to die from canine parvovirus (CPV) infection.

DESIGN

Retrospective, January 2009 to March 2020.

SETTING

A private, small animal, urban, referral emergency and specialty hospital.

ANIMALS

Fifty-nine client-owned dogs hospitalized for treatment of CPV.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Dogs were divided into mSepsis-2 and mSepsis-3 categories based on the highest level of illness severity reached during hospitalization. Greater illness severity based on mSepsis-2 criteria (ie, sepsis, severe sepsis, septic shock) was associated with an increase in average length of stay (P < 0.001), increase in average cost of stay (P < 0.01), and presence of leukopenia (P < 0.05). An increase in illness severity within the mSepsis-2 criteria was not associated with hyperlactatemia (P = 0.29), presence of neutropenia (P = 0.12), or mortality (P = 0.35). Greater illness severity based on mSepsis-3 criteria (ie, infection only, sepsis, septic shock) was associated with an increase in mortality (P < 0.05), increase in average length of stay (P < 0.001), increase in average cost of stay (P < 0.01), presence of leukopenia (P < 0.01), and presence of neutropenia (P < 0.05). The mSepsis-3 criteria were not associated with the presence of hyperlactatemia (P = 0.68). There was no significant difference between survivors and nonsurvivors in the presence of leukopenia (P = 0.19), neutropenia (P = 0.67), or hyperlactatemia (P = 0.58).

CONCLUSIONS

The mSepsis-3 diagnostic criteria appear to better identify dogs with CPV at higher risk for mortality compared to the mSepsis-2 criteria.

Evaluating the use of pharmacological stress agents during single-photon emission computed tomography myocardial perfusion imaging tests after inadequate exercise stress test

BACKGROUND

Past clinical trial findings suggest that the availability of regadenoson in a nuclear imaging center may affect real-world center practices related to the transition of patients from an inadequate exercise stress test (EST) to a pharmacological stress agent (PSA).

METHODS AND RESULTS

This was a cross-sectional study using one-on-one telephone interviews with nuclear imaging center staff to facilitate survey development, followed by an online survey to evaluate patterns and processes around use of PSAs during single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in patients with inadequate ESTs. Of the 50 participants, 35 (70%) used only regadenoson, 3 (6%) only adenosine, 3 (6%) regadenoson and adenosine, 7 (14%) regadenoson and dipyridamole, and 2 (4%) all 3 agents for converting patients from an inadequate EST to a PSA. Nearly all centers (94%) used protocols to guide conversions. Of 12 centers using > 1 PSA, 11 reported regadenoson to be the most preferred PSA. Total staff time required from PSA transition to post-test monitoring was shortest for regadenoson.

CONCLUSIONS

Compared to adenosine and dipyridamole, regadenoson is preferred by nuclear imaging center staff and associated with operational efficiencies after inadequate EST in real-world practice SPECT-MPI.

863. Pre-Exposure Prophylaxis (PrEP) Prescriptions among Individuals at High Risk for HIV in the United States, 2012-2018

Background

To describe trends in emtricitabine and tenofovir disoproxil fumarate (FTC/TDF) PrEP uptake in 2012-2018 and characterize high risk individuals who use PrEP.

Methods

The study identified individuals aged ≥ 15 years old with claims suggesting high risk for HIV infection in the IBM MarketScan® Commercial Claims and Multi-state Medicaid Databases. High risk was defined using ICD codes indicating high risk sexual behavior or rectal/repeated bacterial sexually transmitted infection (STI). The index date was defined as the earliest of the first high risk sexual behavior diagnosis, the first rectal bacterial STI diagnosis, or the second non-rectal bacterial STI diagnosis within 12 months. Individuals were considered PrEP users if they had at least one FTC/TDF PrEP prescription within 12 months of index date. Individuals with evidence of HIV prior to or within 30 days after PrEP initiation/index date were excluded. Comorbidities were assessed using a modified Charlson Comorbidity Index that excluded HIV/AIDS.

Results

FTC/TDF PrEP uptake increased from 0.1% to 7.3% among commercially insured individuals between 2012-2018, and from 0.01% to 0.5% among Medicaid insured individuals between 2012-2017. Individuals ≥ 35 years old had the largest increase in PrEP uptake (0.1% to 13.0%), while those 16-25 years old had the smallest increase (0.03% to 2.3%). The largest proportion of PrEP users across all years were aged 25-34 while the largest proportion of non-PrEP users were aged 18-24. Compared to PrEP users, a larger proportion of PrEP non-users were female (62.9% vs. 1.4%, p < 0.05) and blacks/African American (49.1% vs. 40.3%, p < 0.05). A larger proportion of PrEP users had a risk status of homosexual (46.6% vs. 1.5%, p < 0.05) or bisexual (3.9% vs. 0.8%, p < 0.05) behavior than non-PrEP users. PrEP users also had more comorbidities than non-users among individuals with Medicaid and were less likely to have fee-for-service insurance plans overall (p < 0.05).

Table 1. Characteristics of people at high-risk for HIV who do vs. do not use FTC/TDF PrEP measured during the follow-up period

Conclusion

Despite an increase in FTC/TDF PrEP initiations, uptake was low, especially among young adults, women, heterosexuals and blacks/African Americans. Low initiation rates in these groups may illustrate that FTC/TDF PrEP is not meeting the needs of all high-risk individuals.

Disclosures

Mo Zhou, PhD, Merck & Co., Inc. (Consultant) Yan Song, PhD, Merck & Co., Inc. (Consultant) Emily Gao, MS, MPH, Merck & Co., Inc. (Consultant) Yohance Whiteside, PhD, MSPH, Merck & Co., Inc. (Employee) Emma Billmyer, BA, Merck & Co., Inc. (Consultant) James Signorovitch, PhD, Merck & Co., Inc. (Consultant)

1372. Comparison of Healthcare Resource Utilization (HRU) Among Adult Patients Treated with Omadacycline (OMC) for Acute Bacterial Skin and Skin Structure Infections (ABSSSI) or Community-Acquired Bacterial Pneumonia (CABP) in the 30 Day Pre- and Post-OMC Prescription (Rx)

Background

Assess 30-day real-world outcomes associated with OMC for the treatment of adults with ABSSSI or CABP. Thirty-day outcomes are an important quality metric for both private and public payers. This retrospective study compared HRU among adult pts treated with OMC for ABSSSI or CABP in the 30-day pre- and post-OMC Rx periods. The pre-post study design was selected to assess how 30-day HRU changed post-OMC RX (proxy for treatment response).

Methods

Pts who received ≥1 OMC outpatient Rx from a large US claims database (10/2018-9/2020) were identified. Pts were classified as ABSSSI or CABP cohort based on presence of ICD-10 code near (-90 d to +30 d) OMC Rx. Within each diagnosis, pts were classified as complicated if any of the following infections were identified in the pre-period (-90 d to + 5 d) (ABSSSI: osteomyelitis (OST), sepsis/bacteremia (S/B), endocarditis, implant, necrotizing fasciitis, meningitis; CABP: severe pneumonia, lung abscess, S/B, endocarditis, meningitis). Risk of inpatient admissions (IP), ED visits, outpatient visits (OP) were compared between the following 2 periods: 30 days pre- and 30-days post-OMC Rx.

Results

During study period, 258 OMC outpatient Rx met inclusion criteria: 189 were ABSSSI and 69 were CABP. Among the 189 ABSSSI pts, 83 were complicated. Most common ABSSSI complicated were OST (53%), S/B (33%), and implant infection (21%). Among the 69 CABP pts, 20 were COM. Most common CABP complicated were S/B (80%) and severe pneumonia (25%). Comparison of HRU in the 30 days pre- to the 30-day post-OMC Rx period are shown in Tables 1 and 2. Among complicated ABSSSI pts, IP decreased by 38% (41% vs 25%; p&lt; 0.05) while ED visits and OP were similar. Among non- complicated ABSSSI pts, IP decreased by 61% (17% vs 7%; p&lt; 0.05), ED visits decreased by 88% (16% vs 2%; p&lt; 0.01) while OP were similar. Among complicated CABP pts, IP decreased by 75% (80% vs 20%; p&lt; 0.01), ED decreased by 100% (40% vs 0%; p&lt; 0.001) while OP were similar. Among non- complicated CABP pts, IP decreased by 75% (33% vs 8%; p&lt; 0.01), while ED visits and OP were similar.

Table 1. Comparison of HRU in the 30-day pre-OMC Rx vs 30-day post-OMC Rx period among ABSSSI pts

Conclusion

This study provided the first real world characterization of pts treated with OMC for ABSSSI or CABP. Patients who received OMC had lower HRU in the 30-days post- OMC Rx period relative to the 30-day pre-OMC Rx period.

Disclosures

Thomas Lodise, Jr., PharmD, PhD, Astra-Zeneca (Consultant)Bayer (Consultant)DoseMe (Consultant, Advisor or Review Panel member)ferring (Consultant)genentech (Consultant)GSK (Consultant)Melinta (Consultant)merck (Consultant, Independent Contractor)nabriva (Consultant)paratek (Consultant, Advisor or Review Panel member, Speaker’s Bureau)shionogi (Consultant, Advisor or Review Panel member, Speaker’s Bureau)Spero (Consultant)tetraphase (Consultant)Venatrox (Consultant) Thomas Lodise, Jr., PharmD, PhD, Melinta Therapeutics (Individual(s) Involved: Self): Consultant; Merck (Individual(s) Involved: Self): Consultant, Scientific Research Study Investigator; Paratek (Individual(s) Involved: Self): Consultant; Shionogi (Individual(s) Involved: Self): Consultant, Speakers’ bureau; Spero (Individual(s) Involved: Self): Consultant; Tetraphase Pharmaceuticals Inc. (Individual(s) Involved: Self): Consultant Kyle Gunter, PharmD, MBA, Paratek Pharmaceuticals, Inc. (Employee, Shareholder) Mauricio Rodriguez, Jr., PharmD, BCPS, BCCCP, BCIDP, Paratek Pharmaceuticals, Inc. (Employee, Shareholder) Fan Miu, PhD, Analysis Group (Employee, Other Financial or Material Support, Analysis Group received consulting fees from Paratek Pharmaceuticals, Inc.) Emily Gao, MS, MPH, Merck & Co., Inc. (Consultant) Danni Yang, BA, Analysis Group (Employee, Other Financial or Material Support, Analysis Group received consulting fees from Paratek Pharmaceuticals, Inc.) Steve Sandor, JD, MBA, Paratek Pharmaceuticals, Inc. (Employee, Shareholder) Gail Berman, MD, Paratek Pharmaceuticals, Inc. (Employee, Shareholder)

Factors that impact a patient's experience when undergoing single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in the US: A survey of patients, imaging center staff, and physicians

BACKGROUND

Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is commonly used for coronary artery disease diagnosis/assessment in the United States (US); however, the factors that most significantly affect patients' experience when undergoing SPECT-MPI are not well known.

METHODS

In this US-based cross-sectional study, an online questionnaire was used to identify and quantify attributes of the SPECT-MPI process that impact patients' experience, according to adults who underwent SPECT-MPI in the prior month, cardiac imaging center staff, and referring physicians. Participants were asked to rate the importance of 32 factors using an 11-point scale; congruence between groups (physicians vs patients, patients vs imaging center staff, and physicians vs imaging center staff) was assessed.

RESULTS

The survey was completed by 101 patients, 101 center staff, and 100 physicians, who gave similar ratings for the highest-rated factors (high-quality results/decreasing likelihood of having to retest, highly skilled and knowledgeable staff, and compassionate and respectful staff). Congruence was higher between patients and imaging center staff compared with physicians and patients, and was notably low between imaging center staff and physicians.

CONCLUSIONS

We identified areas for improvement in the patient SPECT-MPI experience that could translate into improved quality and value.

Undiagnosed liver diseases

The landscape of chronic liver disease has drastically changed over the past 20 years, largely due to advances in antiviral therapy and the rise of metabolic syndrome and associated non-alcoholic fatty liver disease (NAFLD). Despite advances in the diagnosis and treatment of a variety of liver diseases, the burden of chronic liver disease is increasing worldwide. The first step to addressing any disease is accurate diagnosis. Here, we discuss liver diseases that remain undiagnosed, either because they are difficult to diagnose or due to hepatic manifestations of an unrecognized systemic disease. Additionally, their underlying etiology may remain unknown or they represent previously uncharacterized and therefore novel liver diseases. Our goal is to provide a framework for approaching undiagnosed liver diseases which elude standard hepatic diagnostic work-up and whose patterns of disease are often overlooked.

Home quarantine compliance is low in children with fever during COVID-19 epidemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak began in China at the end of 2019. The disease is highly infectious. In order to prevent and control the epidemic situation, the state has issued a series of measures to guide the prevention and control of the epidemic. At the same time, it also introduced the measure of home isolation for children with fever. However, due to the nature of children, the implementation of the home isolation turned out to be quite difficult, and questions regarding the home isolation were brought out by parents when seeing doctors. For this reason, we decided to conduct this study.

AIM

To study factors that influence home quarantine compliance in children with fever during the COVID-19 epidemic.

METHODS

A total of 495 paediatric patients with respiratory tract infection and fever were selected from the general fever clinic at Xiamen Children's Hospital from February 6-27, 2020. On day 8 after the hospital visit, follow-up was conducted by telephone to evaluate the compliance of home quarantine.

RESULTS

Among the ten quarantine measures, the proportion of families adhering to keeping 1.5 m distance, proper hand hygiene, wearing masks at home, and proper cough etiquette was very low (< 30% for each measure). Our analysis showed that compliance was related to gender and age of children, gender and age of primary caregiver, number of children in the family, and intensity of information on quarantine measures. We observed that compliance increased with the age of children. Compared with children whose caregivers were young adults, children with elderly caregivers were 2.461 times more likely to show poor compliance. Furthermore, children who received intensive information on quarantine measures had significantly better compliance.

CONCLUSION

Compliance of children with fever to quarantine measures at home is low during the COVID-19 epidemic. Strengthening education on the quarantine measures is critical to improve compliance, in particular in young children with elderly caregivers.

Retrospective analysis of comorbidities and treatment burden among patients with HIV infection in a US Medicaid population

Objective: Comorbidities and comedications are important factors influencing optimal therapy because people are living longer with HIV infection. This study describes the long-term comorbidity profile and treatment burden among people with HIV-1 infection.Methods: This retrospective study included Medicaid claims data from patients with ≥1 antiretroviral (ARV) claim between 2016 and 2017 (most recent claim defined the index date), ≥1 HIV diagnosis within 1 year before index, age ≥18 years at first HIV diagnosis and <65 years at index, ≥12 months of continuous eligibility before index, and no history of HIV-2 infection. Comorbidities, concomitant medication use, and pill burden were assessed in the 4 years before index. Analyses were stratified by patient age and treatment experience.Results: Among 3456 patients, the mean (standard deviation [SD]) age was 47.1 (10.4) years; the majority were black (55%) and men (63%). In general, the prevalence of comorbidities increased from the fourth year to the first year before index and included cardiovascular disease (28-40%), hypertension (24-37%), hyperlipidemia (12-17%), and asthma/chronic obstructive pulmonary disease (13-19%). Concomitant medication use corresponding to these comorbidities slightly increased over time. In the year before index, mean (SD) daily pill burden was 2.1 (1.4) for ARVs and 5.9 (5.9) for non-ARVs. Older age and prior treatment experience were associated with higher rates of comorbidities and greater pill burden.Conclusions: In people with HIV infection, comorbidities and concomitant medication use increased with age, supporting considerations for streamlined ARV regimens highlighted in treatment guidelines.

Abstract 340: Evaluating the Use of Pharmacological Stress Agents During Single-photon Emission Computed Tomography Myocardial Perfusion Imaging Tests After Inadequate Exercise Stress Test

Objective: To evaluate how pharmacological stress agents (PSAs) are used during single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) for patients (pts) with an inadequate exercise stress test (EST).

Methods: This was a cross-sectional study. One-on-one telephone interviews with nuclear imaging center staff were used to develop an online survey, which was administered to evaluate patterns/processes around PSA use during SPECT-MPI in pts with inadequate EST. Eligible survey participants included nuclear technicians, nurses, physicians, and imaging center managers/directors with sufficient familiarity with SPECT-MPI/use of PSAs. Primary endpoint measures included gaining insights on how imaging centers convert to PSAs after inadequate EST and associated resource use.

Results: Of 50 participating centers, 35 (70%) used only regadenoson (REG), 3 (6%) only adenosine (ADN), 3 (6%) REG and ADN, 7 (14%) REG and dipyridamole (DP), and 2 (4%) all 3 agents for converting pts after inadequate EST. Most centers (94%) used protocols to guide conversions. Post-test monitoring, including monitoring of pt performance and managing adverse reactions after completion of SPECT-MPI following PSA, was not conducted by 66%, 38%, and 56% of centers using REG, ADN, and DP, respectively. Same-day conversion occurred for 92%, 89%, and 98% of pts for REG, ADN, DP, respectively; the mean (standard deviation) number of pts converted in the past 30 days were 29.6 (44.1), 9.3 (9.9), and 1.9 (1.8), respectively. After an inadequate EST, average pt wait times to receiving REG, ADN, or DP were 4.9, 12.4 or 17.4 min, respectively; among centers using REG, 60% administered the PSA within a mean of 3 min, compared to 11% (1 center) using DP and no centers using ADN. Nearly 100%, 38%, and 11% of REG, ADN, and DP centers, respectively, reported that PSA administration was “not at all complex.” Of the centers using >1 PSA, 92% found REG to be the most preferred PSA (overall) among staff. Total staff time (aggregating time for multiple staff members who may have worked concurrently at each step) required from PSA transition to post-test monitoring was shortest for REG ( Table ).

Conclusions: Imaging center staff prefer REG and its use is associated with operational efficiencies during SPECT-MPI after inadequate EST.

Multiorgan microfluidic platform with breathable lung chamber for inhalation or intravenous drug screening and development

Efficient and economical delivery of pharmaceuticals to patients is critical for effective therapy. Here we describe a multiorgan (lung, liver, and breast cancer) microphysiological system ("Body-on-a-Chip") designed to mimic both inhalation therapy and/or intravenous therapy using curcumin as a model drug. This system is "pumpless" and self-contained using a rocker platform for fluid (blood surrogate) bidirectional recirculation. Our lung chamber is constructed to maintain an air-liquid interface and contained a "breathable" component that was designed to mimic breathing by simulating gas exchange, contraction and expansion of the "lung" using a reciprocating pump. Three cell lines were used: A549 for the lung, HepG2 C3A for the liver, and MDA MB231 for breast cancer. All cell lines were maintained with high viability (>85%) in the device for at least 48 hr. Curcumin is used to treat breast cancer and this allowed us to compare inhalation delivery versus intravenous delivery of the drug in terms of effectiveness and potentially toxicity. Inhalation therapy could be potentially applied at home by the patient while intravenous therapy would need to be applied in a clinical setting. Inhalation therapy would be more economical and allow more frequent dosing with a potentially lower level of drug. For 24 hr exposure to 2.5 and 25 µM curcumin in the flow device the effect on lung and liver viability was small to insignificant, while there was a significant decrease in viability of the breast cancer (to 69% at 2.5 µM and 51% at 25 µM). Intravenous delivery also selectively decreased breast cancer viability (to 88% at 2.5 µM and 79% at 25 µM) but was less effective than inhalation therapy. The response in the static device controls was significantly reduced from that with recirculation demonstrating the effect of flow. These results demonstrate for the first time the feasibility of constructing a multiorgan microphysiological system with recirculating flow that incorporates a "breathable" lung module that maintains an air-liquid interface.

Discovery of Nonpeptide, Reversible HER1/HER2 Dual-Targeting Small-Molecule Inhibitors as Near-Infrared Fluorescent Probes for Efficient Tumor Detection, Diagnostic Imaging, and Drug Screening

The abnormal expression of epidermal growth factor receptors HER1(EGFR) and HER2 is strongly associated with cancer invasion, metastasis, and angiogenesis. Their molecular detection is mainly executed using genetically encoded or antibody-based diagnostic tracers, but no dual-targeting small-molecule bioprobe has been achieved. Here, we report the novel small-molecule fluorescent probes Cy3-AFTN and Cy5-AFTN as potent dual-targeting inhibitors for efficient detection of HER1/HER2 expression in cancer cells and in vivo tumor diagnostic imaging. Unlike the irreversible HER1/HER2 inhibitors, Cy3-AFTN and Cy5-AFTN were designed as reversible/noncovalent probes based on the clinical drug afatinib, by making the molecule structurally impossible for receptor-mediated Michael additions. The synthesized probes were validated with live cell fluorescence imaging, flow cytometry and confocal-mediated competitive binding inhibition, molecular docking study, and in vivo xenograft tumor detection. The probes are competitively replaceable by other HER1/HER2 inhibitors; thus, they are potentially useful in fluorometric high-throughput screening for drug discovery.

Impact of Hormone Therapy on Laboratory Values in Transgender Patients

BACKGROUND

For transgender individuals taking hormone therapy (HT), data on laboratory values are limited, and the effects on laboratory values cannot be easily predicted. We evaluated the impact on common laboratory analytes in transgender individuals before and after initiation of HT.

METHODS

We conducted a retrospective chart review of transgender patients identified at transgender-specific clinics at an urban county hospital and community clinic. Laboratory data were collected on hormone concentrations, hematologic parameters, electrolytes, lipids, and liver and renal markers before and after initiation of HT.

RESULTS

We identified 183 transgender women (TW) and 119 transgender men (TM) for whom laboratory data were available. In all, 87 TW and 62 TM had baseline laboratory data, and data were also available for 133 TW and 89 TM on HT for &gt;6 months. The most significant changes were seen in red blood cell count, hemoglobin concentration, hematocrit, and creatinine levels after &gt;6 months of HT, which increased in TM and decreased in TW after HT (P &lt; 0.005; d index &gt; 0.6). Alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase levels increased in TM; however, the effect size was small (d index &lt; 0.5). Calcium, albumin, and alkaline phosphatase levels significantly decreased in TW (P &lt; 0.001; d &gt; 0.6). Additionally, TM were found to have increased triglycerides and decreased HDL levels (P &lt; 0.005; d &gt; 0.6).

CONCLUSIONS

Changes occur in several common laboratory parameters for patients on HT. Some laboratory values changed to match the gender identity, whereas others remained unchanged or were intermediate from the baseline values. These findings will help guide interpretation of laboratory test results in transgender patients taking HT.

NLRP3 inflammasome activation during myocardial ischemia reperfusion is cardioprotective

BACKGROUND

The innate immune receptor NLRP3 recognizes tissue damage and initiates inflammatory processes through formation multiprotein complexes with the adaptor protein ASC and caspase-1, i.e. NLRP3 inflammasomes, which through cleavage of pro-IL-1β mediates release of bioactive IL-1β. We hypothesized that NLRP3 mediates tissue damage during acute myocardial infarction (MI) and sought to investigate the mechanisms herein in an experimental MI model in mice.

METHODS AND RESULTS

The left coronary artery (LCA) of WT, NLRP3(-/-) and ASC(-/-) mice of both genders was ligated for 30 min followed by 3 or 24 h reperfusion. For pre-conditioning studies, the TLR2 agonist Pam3CSK4 or PBS was injected intraperitoneally 60 min prior to LCA ligation. For mechanistic investigations, blood plasmas and left ventricle tissues were collected, and a hypothesis-driven selection of protein or mRNA targets was investigated. Surprisingly, hearts from NLRP3-deficient mice featured larger infarct size than WT mice (p = 0.0048). In general, there were only modest changes with no significant pattern in myocardial infiltration of neutrophils and macrophages and systemic and myocardial cytokine expression between the three genotypes. Preconditioning with the TLR2 agonist Pam3CSK4 induced Akt phosphorylation and reduced infarct size in WT but not NLRP3 -or ASC -deficient hearts.

CONCLUSION

Absence of NLRP3 results in increased myocardial infarct size after in vivo ischemia reperfusion, seemingly due to dysfunction of the cardioprotective RISK pathway. Our data imply that NLRP3 contributes to cardio-protection during I/R and do not support a role for NLRP3 or ASC inhibition in the management of acute MI including revascularization therapy.

Myocardial β(2) -adrenoceptor gene delivery promotes coordinated cardiac adaptive remodelling and angiogenesis in heart failure

BACKGROUND AND PURPOSE

We investigated whether β(2) -adrenoceptor overexpression could promote angiogenesis and improve blood perfusion and left ventricular (LV) remodeling of the failing heart.

EXPERIMENTAL APPROACH

We explored the angiogenic effects of β(2) -adrenoceptor overexpression in a rat model of post-myocardial infarction (MI) heart failure (HF). Cardiac adenoviral-mediated β(2) -adrenoceptor overexpression was obtained via direct intramyocardial injection 4-weeks post-MI. Adenovirus(Ad)-GFP and saline injected rats served as controls. Furthermore, we extended our observation to β(2) -adrenoceptor -/- mice undergoing MI.

KEY RESULTS

Transgenes were robustly expressed in the LV at 2 weeks post-gene therapy, whereas their expression was minimal at 4-weeks post-gene delivery. In HF rats, cardiac β(2) -adrenoceptor overexpression resulted in enhanced basal and isoprenaline-stimulated cardiac contractility at 2-weeks post-gene delivery. At 4 weeks post-gene transfer, Ad-β(2) -adrenoceptor HF rats showed improved LV remodeling and cardiac function. Importantly, β(2) -adrenoceptor overexpression was associated with a markedly increased capillary and arteriolar length density and enhanced in vivo myocardial blood flow and coronary reserve. At the molecular level, cardiac β(2) -adrenoceptor gene transfer induced the activation of the VEGF/PKB/eNOS pro-angiogenic pathway. In β(2) -adrenoceptor-/- mice, we found a ~25% reduction in cardiac capillary density compared with β(2) -adrenoceptor+/+ mice. The lack of β(2) -adrenoceptors was associated with a higher mortality rate at 30 days and LV dilatation, and a worse global cardiac contractility compared with controls.

CONCLUSIONS AND IMPLICATION

β(2) -Adrenoceptors play an important role in the regulation of the angiogenic response in HF. The activation of VEGF/PKB/eNOS pathway seems to be strongly involved in this mechanism.

Plasma soluble HLA-G is a potential biomarker for diagnosis of colorectal, gastric, esophageal and lung cancer

Human leukocyte antigen-G (HLA-G) is a novel tumor marker and its soluble isoforms produce secretory proteins. Increased soluble HLA-G (sHLA-G) levels have been reported in patients with melanoma, neuroblastoma, lymphoproliferative disorders, breast, ovarian and colorectal carcinoma when compared to healthy controls or subjects with benign neoplasms. The aim of this study is to investigate whether or not plasma sHLA-G can be used as a potential biomarker for cancer diagnosis. We measured plasma sHLA-G levels in 166 patients with early stages of colorectal cancer (CRC, n = 37), gastric cancer (GC, n = 28), esophageal squamous cell carcinoma (ESCC, n = 58) and non-small cell lung cancer (NSCLC, n = 43), and compared them to healthy controls (n = 260) by using a specific HLA-G enzyme-linked immunosorbent assay (ELISA). We found that plasma sHLA-G levels were significantly higher in cancer patients than in healthy controls (all P < 0.0001). The areas under the receiver-operating characteristic (ROC) curves for sHLA-G were 0.97, 0.91, 0.98 and 0.80 for healthy controls vs CRC, GC, ESCC and NSCLC, respectively. At 100% specificity, the highest sensitivity achieved to detect CRC, GC, ESCC and NSCLC was 94% [95% confidence interval (CI), 89-99], 85% (95% CI, 76-94), 91% (95% CI, 88-94) and 51% (95% CI, 43-59) at a cutoff value of 49 U/ml, respectively. These findings suggest that plasma sHLA-G may be a useful molecule in the differential diagnosis of these malignancies against healthy controls.

Induced abortion and duration of third stage labour in a subsequent pregnancy

We set out to evaluate the impact of first trimester induced abortion on the duration of third stage labour and related complications in a subsequent pregnancy. The study was conducted in Shanghai city at 15 general hospitals (or maternity and infant health institutes) from November 1993 to March 1998. We identified all nulliparae who came for antenatal care within the first 63 days of pregnancy (2953); the women were divided into two cohorts according to their previous history of first trimester induced abortion. After enrollment, the women were interviewed five times from recruitment until 42 days after delivery. We included in the study all 1363 women who had a singleton vaginal live birth. Of these women, 703 were primigravida (non-exposed), 534 had had one previous first trimester induced abortion, and 126 women had had two or more first trimester induced abortions. The duration of third stage labour in minutes was longer in women with one or more previous induced abortions (mean=7.32 minutes) compared with primigravid women (mean=6.79 minutes). Prolonged third stage labour (>30 minutes) following one or more induced abortions was seen for 3.4% versus 1.0% in primigravid women. After adjusting for a number of potential confounders, women with one or more previous first trimester induced abortions had an odds ratio of prolonged third stage labour of 2.59 (95%C.I.=1.06-6.37) compared with primigravida, especially after an interpregnancy interval of more than 6 months (OR=3.24, 95%C.I.=1.29-8.13). The odds ratio of prolonged third stage labour was 3.14 (95%C.I.=1.22-8.09) if gestational age at the time of the induced abortion exceeded 49 days. Women with a first trimester induced abortion had no significantly increased risk of postpartum haemorrhage or retained placenta. It was concluded that a history of one or more first trimester induced abortions was related to an increased risk of prolonged third stage labour in the following pregnancy, particularly if the induced abortion was performed after 49 days of gestation.

Fetal macrosomia and adolescence obesity: results from a longitudinal cohort study

OBJECTIVE

To assess the association between fetal macrosomia and adolescent obesity.

DESIGN

Longitudinal cohort study of the association between macrosomia and adolescent obesity.

SUBJECTS

Between 1 October 2005 and 1 February 2007, a follow-up study of live-born infants born in 1993-1995 in Wuxi, a suburban area of Shanghai, was conducted. Subjects with birth weight > 4000 g were selected as the exposed. For each exposed subject, one subject with a birth weight of 2500-4000 g, matched by year of birth, sex of infant, and type of institute at birth, was chosen as non-exposed. Clinical data were collected by structured interview and physical examination. Obesity was defined as body mass index (weight (kg)/height (m(2))) higher than the sex-age-specific criteria by the working group on obesity in China. Distribution of baseline characteristics and adolescent obesity rate between the exposed and non-exposed groups was compared.

RESULTS

A total of 1435 pairs of exposed and non-exposed subjects were included in the final analysis. No major difference in baseline characteristics (other than birth weight) was found between the exposed and non-exposed groups. Obesity rate was significantly higher in the exposed group (2.9%) than in the non-exposed group (1.6%). Adolescent obesity rates were 1.4, 1.9, 2.6, and 5.6%, respectively, in study subjects with a birth weight of 2500-3499, 3500-3999, 4000-4499, and > or =4500 g. The association between birth weight and adolescent obesity remained essentially the same when mother's demographic and anthropometric factors, breast feeding, and adolescent life-style factors were adjusted.

CONCLUSION

Compared with infants of normal birth weight, infants with birth weight >4000 g, especially those >4500 g, are at increased risk of adolescent obesity.

Thioredoxin reduces post-ischemic myocardial apoptosis by reducing oxidative/nitrative stress

BACKGROUND AND PURPOSE

Thioredoxin (Trx) is an oxidoreductase that prevents free radical-induced cell death in cultured cells. Here we assessed the mechanism(s) underlying the cardioprotective effects of Trx in vivo.

EXPERIMENTAL APPROACH

The effects of myocardial ischemia (30 min) and reperfusion were measured in mice, with assays of myocardial apoptosis, superoxide production, NOx and nitrotyrosine content, and myocardial infarct size. Recombinant human Trx (rhTrx, 0.7-20 mg kg(-1), i.p.) was given 10 min before reperfusion.

KEY RESULTS

Treatment with 2 mg kg(-1) rhTrx significantly decreased myocardial apoptosis and reduced infarct size (P<0.01). Nitrotyrosine content of cardiomyocytes was markedly reduced in rhTrx-treated animals (P<0.01). To further identify the mechanisms by which rhTrx may exert its anti-nitrative effect, iNOS expression and production of NOx and superoxide were determined. Treatment with rhTrx had no significant effect on iNOS expression or NOx content in the ischemic/reperfused heart. However, it markedly upregulated mSOD and reduced tissue superoxide content. To further establish a causative link between the anti- peroxynitrite effect and the cardioprotective effect of rhTrx, cultured adult cardiomyocytes were incubated with SIN-1, a peroxynitrite donor, (50 microM for 3 h) resulting in a nitrotyrosine content comparable to that seen in the ischemic/reperfused heart and causing significant cardiomyocyte apoptosis (P<0.01). Treatment with rhTrx markedly decreased SIN-1 induced apoptosis (P<0.01).

CONCLUSIONS AND IMPLICATIONS

These results demonstrate that Trx is a novel anti-apoptotic and cardioprotective molecule that exerts its cardioprotective effects by reducing ischemia/reperfusion-induced oxidative/nitrative stress.

Early anti-apoptosis treatment reduces myocardial infarct size after a prolonged reperfusion

OBJECTIVE

Significant myocardial apoptosis occurs in ischemia/reperfused hearts. However, the contribution of apoptosis to the development of myocardial injury remains controversial. The present study attempted to obtain evidence that inhibition of apoptosis at early reperfusion can reduce myocardial infarction after prolonged reperfusion.

METHODS

Adult male rats were subjected to 30 min ischemia and 4 (apoptosis assay) or 24 h (myocardial infarction determination) of reperfusion and treated with vehicle, SB 239063, insulin or insulin plus wortmannin.

RESULTS

Treatment with SB 239063 or insulin markedly decreased myocardial apoptosis (10.6 +/- 1.5% and 7.9 +/- 0.9% respectively, P < 0.01 vs. vehicle) and significantly reduced infarct size (43 +/- 3.6% and 35 +/- 2.9%, respectively, P < 0.01 vs. vehicle). Most interestingly, inhibition of insulin signaling with wortmannin to block insulin signaling not only blocked insulin's anti-apoptotic effect, but also abolished its infarct reduction property.

CONCLUSION

These data indicate that apoptosis contributes to the development of myocardial infarction, and inhibition of apoptosis at early reperfusion reduces the myocardial infarction.

Summary evaluations of risk factors related to infant mortality

The authors discuss risk factors related to infant mortality. "The size and magnitude of these risk factors vary across different countries and regions. In order to more accurately describe the relationship between risk factors and infant mortality, risk factors should be quantified, making it possible to estimate the degree of risk associated with infant deaths. This article introduces some risk factors and their evaluation method."

Adenosine A1 receptor antagonist prolongs survival in the hypoxic rat

The hypothesis that adenosine A1 receptor (A1AdoR) selective antagonism limits cardiac depression and prolongs survival during acute global hypoxia was tested in a postinsult treatment model using KW-3902 ([8-(noradamantan-3-yl)-1,3-dipropylxanthine]), an A1AdoR selective antagonist. Rats were anesthetized, paralyzed, then ventilated with 8% O2 (hypoxia). In protocol I, 5 min after hypoxia, rats were treated with saline, drug vehicle, or KW-3902 (0.1 mg/kg i.v.). In protocol II, KW-3902 treatment occurred 2.5, 5, or 7.5 min after hypoxia. In protocol I, after hypoxia, left ventricular contractility, heart rate, and systemic mean arterial blood pressure decreased rapidly in saline-and vehicle-treated groups. In contrast, KW-3902 significantly attenuated the decline in these variables. Survival time (the time from the commencement of hypoxia until death) was more prolonged with KW-3902 (109.5 +/- 9.1 min) than with saline (37.6 +/- 5.0 min) or vehicle (35.0 +/- 4.2 min) (p < 0.001). In protocol II, survival time increased from 29.2 +/- 5.5 min in the 7.5-min treatment group to 109.5 +/- 9.5 min (5-min group) and 245.9 +/- 26.1 min (2.5-min group; p < 0.001). KW-3902 prolongs survival in this model, presumably by antagonizing A1AdoR-mediated inhibition of cardiac function. Also, treatment efficacy is highly time dependent.

[Effect of Shajiang black soil amended by coal fly ash on ecological factors and residue of heavy metal in wheat field]

The effect of Shajiang black soil amended by coal fly ash on ecological factors in wheat field and residua of Cd, Cr, Pb, Hg and As were studied by pot experiment. The results showed that applying coal fly ash into Shajiang black soil could decrease soil density, soil proportion and clay content, but increase soil porosity, filtration coefficient and soil temperature. Moreover, it could promote water evaporating when soil moisture was high and keep soil water when lower than 10%. It also could facilitate activity of soil micro-organism and promote soil nutrient transforming. With (6-18) x 10(4) kg.hm-2 coal fly ash applied in Shajiang black soil, the accumulated quantity of Cd, Cr, Pb, Hg and As in soil and in wheat grain were lower than international standard index of pollution. Therefor, Shajiang black soil amended by coal fly ash was safe and reliable within the above range.

Vanadium, molybdenum, and sodium triethanolamine complexes derived from an assembly system containing tetrathiometalate and triethanolamine

The reaction system composed of triethanolamine (TEA) and tetrathiovanadate in the presence of MeONa (MeOLi) or NaNH2 was studied to afford vanadium and alkali metal TEA complexes. Complexes [M subsetV6O6[N(CH2CH2O)2(CH2CH2OH)]6]2S6 (M = Na (1), Li (2)) contain two cyclic V((IV)) [12]metallacrown-6 cations linked by a polysulfide S6(2-) anion. Also separated from the reaction system is a novel sodium TEA complex [[Na(TEA)]2S6]n (3), in which parallel coordination chains [Na(TEA)+]n are connected by O-H...S hydrogen bonds forming 3-D network structure. Variable-temperature conductance of 3 was determined to display semiconductor feature. The desulfurization of VS4(3-) was observed to form S6(2-) anion and/or S8 molecule in the synthetic reactions of 1-3. A striking contrast was noted that MoS4(2-) did not desulfurize in the similar reaction to that of VS4(3-) with TEA, and a Na/TEA complex containing MoS4(2-), (Et4N)2[Na2(mu-TEA)2(CH3OH)2](MoS4)2 (4), was obtained instead. The S...H-O and O...H-O hydrogen bonds play an important role in forming the one- or three-dimensional structures for all these complexes by the linkages between clusters and chains. The IR spectrum indicates the structural similarity of complexes 1 and 2. For complex 4, the Mo=S stretch vibration at 468 cm(-1) showing widening and slight red-shift and the slight movement of the 1H NMR signals of TEA ligand to downfield are considered to be the influence of the S...H-O hydrogen bonds. Variable temperature magnetic susceptibility data were collected for complex 1. The effect magnetic moment per V6 unit varies gradually from 4.04 muB at 300 K to 6.24 muB at 5 K, exhibiting ferromagnetic interaction. Heisenberg-type vector-coupling model and molecular field approximation were used to treat the interaction between the paramagnetic sites and gave a good fitting result: J = 3.97 cm(-1), J' = 1.99 cm(-1), g = 1.99, F = 3.64 x 10(-3). Density functional calculation was also performed to complex 1 and its Li, K analogues. The lowest total bonding energy of -874.001 eV was obtained for [Na subsetV6(mu3-O)6] complex containing six unpaired electrons, indicating the stability of a V6 system with six independent spins S = 1/2. When the alkali metal ion is inserted into the [V6(mu3-O)6] cavity, the positive values of the bonding interaction (E(b)) indicate that the insertion depresses the total energy and that complexes 1 and 2 together with K+ complex may exist. However, the lowest E(b) value of the K+ complex implies its instability.

Effects of acetylcholine and atropine on plasticity of central auditory neurons caused by conditioning in bats

In the big brown bat (Eptesicus fuscus), conditioning with acoustic stimuli followed by electric leg-stimulation causes shifts in frequency-tuning curves and best frequencies (hereafter BF shifts) of collicular and cortical neurons, i.e., reorganization of the cochleotopic (frequency) maps in the inferior colliculus (IC) and auditory cortex (AC). The collicular BF shift recovers 180 min after the conditioning, but the cortical BF shift lasts longer than 26 h. The collicular BF shift is not caused by conditioning, as the AC is inactivated during conditioning. Therefore it has been concluded that the collicular BF shift is caused by the corticofugal auditory system. The collicular and cortical BF shifts both are not caused by conditioning as the somatosensory cortex is inactivated during conditioning. Therefore it has been hypothesized that the cortical BF shift is mostly caused by both the subcortical (e.g., collicular) BF shift and the activity of nonauditory systems such as the somatosensory cortex excited by an unconditioned leg-stimulation and the cholinergic basal forebrain. The main aims of our present studies are to examine whether acetylcholine (ACh) applied to the AC augments the collicular and cortical BF shifts caused by the conditioning and whether atropine applied to the AC abolishes the cortical BF shift but not the collicular BF shift, as expected from the preceding hypothesis. In the awake bat, we made the following findings. ACh applied to the AC augments not only the cortical BF shift but also the collicular BF shift through the corticofugal system. Atropine applied to the AC reduces the collicular BF shift and abolishes the cortical BF shift which otherwise would be caused. ACh applied to the IC significantly augments the collicular BF shift but affects the cortical BF shift only slightly. ACh makes the cortical BF shift long-lasting beyond 4 h, but it cannot make the collicular BF shift long-lasting beyond 3 h. Atropine applied to the IC abolishes the collicular BF shift. It reduces the cortical BF shift but does not abolish it. Our findings favor the hypothesis that the BF shifts evoked by the corticofugal system, and an increased ACh level in the AC evoked by the basal forebrain are both necessary to evoke a long-lasting cortical BF shift.