Predictors of Prescriber Preference for Expensive Insulins: A Single Institution Survey.

Background: The average cost of insulin has increased greatly recently, partly due to prescription of newer expensive insulins. This has caused insulin underuse among economically vulnerable uninsured patients. Herein, predictors of preference for expensive (higher retail price) insulins among primary care physicians are investigated. Methods: Internal medicine and family medicine attending physicians and residents at West Suburban Medical Center (Oak Park, Illinois, USA) participated in a web-based survey (Qualtrics Survey Platform) via email between October 20, 2020, and November 10, 2020. Baseline characteristics, prescribing preferences (Insulins Ranks, lower rank indicates higher preference), factors determining insulin choice, pricing knowledge, dosing knowledge, and training were recorded. Insulins were classified as "Inexpensive" (retail price ≤ median insulin price) or "Expensive." The mean rank of expensive and inexpensive insulins prescribed were calculated. Participants were divided into either the "Inexpensive Prescription Preferences" (IPP; mean rank of Inexpensive insulins ≤ mean rank of Expensive insulins) or "Expensive Prescription Preferences" (EPP) groups. Groups were compared. Multivariable logistic regression assessed predictors of IPP. Results: The response rate was 78% (72/92). Among the 70 participants included, EPP (n = 43) and IPP participants (IPP, n = 27) had similar baseline characteristics (Physician Role, Specialty, and Practice Type), except EPP physicians graduated earlier (P = 0.011). EPP participants reported prescribing insulin glargine more often (P = 0.018) and also ranked it higher (P < 0.001). Logistic regression identified that previous Endocrine rotations (P = 0.031) and senior Physician Role (P = 0.001) predicted EPP. Conclusion: Previous endocrinology rotations, and senior role predict prescription of insulins with a high retail price. Speculatively, training physicians in cheaper prescription practices may lower costs. Further studies are required to generalize these results.

Language Barriers to Online Search Interest for COVID-19: A Global Infodemiological Study.

Background Implementation of coronavirus disease 2019 (COVID-19) pandemic control measures requires the engagement and participation of the public in a synchronized manner. Language may be a barrier to captivating public interest in a concerted manner. The relative volume of English and non-English COVID-19-related web searches estimate public interest among English and Non-English "searchers," respectively. Asynchrony between English and non-English search interest may suggest language-related lapses in public engagement. Addressing these lapses may improve public health communications. In this study, we aimed to describe the distribution and temporal trends in the evolution of English and non-English online search interest for COVID-19 and to identify lags between English and non-English search interest. Methodology Search interest data (Baidu Index for China, Google Trends for other countries) was queried for the keywords "coronavirus," "covid 19," and their non-English equivalents between January 1, 2019, and September 30, 2020, for each country (n = 230). Daily total, English, and non-English search interest were recorded. Search Interest variables were described at global, regional, and country levels. The cross-correlation function was used to identify lags between English and non-English search interest at global, regional, and country levels. Results Globally, 9.69% of total searches relating to COVID-19 utilized non-English keywords. Among included regions, 64.7% (11/17) had significant non-English interest. Central Asia had the highest proportion of non-English interest (81.13% of total interest), followed by Eastern Europe (56.17%), Eastern Asia, Western Asia, and Northern Africa (all over 20%). Among included countries, 33.5% (77/230) had significant non-English interest. Cross-correlation function identified significant lags between English and non-English Interest in six regions (median lag [interquartile range, IQR]: -0.5 [6.00] days) and 24 countries (median lag [IQR]: -1 [4.25] days). Conclusions Non-English keywords contribute substantially to searches relating to COVID-19 in certain countries and regions. Numerous locations exhibit significant lags between English and non-English search interest, suggesting language-related discrepancies in the interest for COVID-19. Further research is required to address the root cause of these lags.

Personalized Fluoroscopic Angles in Watchman™ Left Atrial Appendage Closure Landing Zone Assessment: A Three-Dimensional Printed Simulation Study.

Background Atrial fibrillation causes ischemic stroke when thrombi dislodge from a cardiac outpouching, the left atrial appendage (LAA), and embolize to the brain. LAA occlusion with the Watchman™ device (Boston Scientific Corporation, MA, USA), which prevents stroke, requires accurate LAA measurements for device sizing. We explore whether standard fluoroscopic LAA measurements improve when obtained at CT-derived viewing angles personalized to LAA anatomy while concurrently referring to three-dimensional (3D) CT. Methods Left atrial 3D reconstructions created from contrast CT (n=28) were analysed to identify personalized viewing angles wherein LAA dimensions (LAA maximum landing zone diameter and LAA length) were best observed. The 3D-CT reconstructions were then 3D printed with stands. Fluoroscopy of anatomically oriented models in the catheter lab simulated LAA angiography. Fluoroscopic images were acquired at standard (caudal 20˚/right anterior oblique 30˚) and personalized viewing angles. Repeated measurements of LAA dimensions were taken from CT (Control), fluoroscopy at standard angles (Standard), personalized angles (Blinded), and personalized angles while concurrently referring to 3D CT (Referred). Results Control measurements correlated and agreed better with Referred and Blinded measurements than with Standard measurements (diameter correlation and agreement: Control/Standard r=.554, limits of agreement [LOAs]=6.83/-5.91; Control/Blinded r=.641, LOA =5.67/-5.54; Control/Referred r=.741, LOA=4.69/-4.14; length correlation and agreement: Control/Standard rs=.829, LOA=9.61/-3.02; Control/Blinded rs=0.789, LOA=7.13/-4.94; Control/Referred rs=.907, LOA=4.84/-4.13). Personalized angles resulted in hypothetical device size predictions more consistent with Control (device size correlation: Control/Standard rs=.698, Control/Blinded rs=.731, Control/Referred rs=.893, P<0.001). False ineligibility rates were Standard=6/28, Blinded=6/28, and Referred=2/28. Conclusion This simulation suggests that personalized fluoroscopic viewing angles with in-procedural reference to 3D CT may improve the accuracy of LAA maximum landing zone diameter and length measurements at the Watchman landing zone. This improvement may result in more consistent device size selection and procedural eligibility assessment. Further clinical research on these interventions is merited.

Clinical efficacy of irrigated catheter application of amiodarone during ablation of persistent atrial fibrillation.

BACKGROUND: Pharmacological treatment during ablation of persistent atrial fibrillation (AF) is common, but utility of irrigated catheter application of amiodarone during ablation of persistent AF remains unclear. HYPOTHESIS: Irrigated catheter application of amiodarone improves quality of ablation and long-term outcomes. METHODS: We enrolled 90 persistent AF patients who underwent catheter ablation. Patients were randomized to the amiodarone group (n = 45) or control group (n = 45). All patients underwent stepwise ablation beginning with isolation of the pulmonary veins. Next, we performed ablation of linear lesions and focal triggers until sinus rhythm (SR) was achieved. The primary endpoint was documented atrial arrhythmia during follow-up. The secondary endpoint was cardioversion to SR during ablation. RESULTS: All pulmonary veins were successfully isolated. Conversion of AF to SR occurred more frequently in the amiodarone group than in the control group (33 vs 23 [73.3% vs 51.1%]; P = 0.03). The amiodarone group had lower procedure, radiofrequency, and fluoroscopy times than the control group (167.4 ± 22.5 min vs 186.7 ± 25.3 min; 78.3 ± 14.2 min vs 90.4 ± 15.5 min; and 6.5 ± 1.9 min vs 8.6 ± 2.4 min, respectively; P < 0.05). More importantly, the atrial arrhythmia recurrence-free survival rates were 80% in the amiodarone group and 60% in the control group during the 14.7 ± 7.5-month follow-up (P = 0.043). CONCLUSIONS: Irrigated catheter application of amiodarone during ablation for persistent AF resulted in higher cardioversion rates and lower procedure times and significantly reduced rates of atrial arrhythmia recurrence.