Trends in the Care of Locally Advanced Pancreatic Cancer in the Modern Era of Chemotherapy.

INTRODUCTION: Current guidelines for treatment for locally advanced pancreatic cancer recommend chemotherapy ± radiation, or radiation alone when multimodal therapy is contraindicated. In a subset of patients, guideline-recommended treatment (GRT) achieves sufficient response to qualify for potentially curative resection. This study evaluated trends in treatment utilization and aimed to identify barriers to GRT. METHODS: Patients with clinical T4M0 disease in the National Cancer Database from 2010 to 2017 were included. Potential predictors were assessed by relative risk regression with Poisson distribution and compared by log-link function. RESULTS: In total, 28 056 patients met the criteria. Among 17 059 (67.67%) patients treated primarily with chemotherapy, 41.19% also had radiation and 8.89% went onto resection. Many received no cancer-directed treatment or failed to receive GRT. Another 710 patients had radiation (±surgery) without chemotherapy despite few contraindications to chemotherapy. Over time, patients were more likely to undergo resection after chemotherapy (aRR = 1.58; p < 0.0001) and less likely to have chemoradiation (aRR = 0.78; p < 0.0001) or go untreated (aRR = 0.90; p < 0.0001). Socioeconomic factors (race, education, income, and insurance status) affected the likelihood of receiving chemotherapy and surgery. Median overall survival (OS) was significantly improved for patients treated with chemotherapy and particularly in those patients who went on to receive RT or undergo surgical resection. OS was also longer for patients treated at high-volume academic centers. Patients insured by Medicaid, Medicare, or those without insurance had worse OS. CONCLUSIONS: Despite improvement over time, many patients go untreated. Clinical factors were influential, but the impact of vulnerable social standing suggests persistent inequity in access to care.

Integrated vascular surgery applicants' perspectives of virtual residency interviews during the coronavirus disease 2019 application cycle.

BACKGROUND: In agreement with Association of American Medical Colleges guidelines, the 2020 to 2021 integrated vascular surgery (I-VS) residency interviews were conducted virtually. In the present study, we collected data about the virtual interview process from the applicant's perspective, including preferences for interview format and the virtual resources they found most helpful. METHODS: An anonymous, online survey study of medical students who had been accepted into I-VS residencies during the 2020 to 2021 application cycle was performed. The survey contained questions about applicant behavior during the virtual application cycle, their perception of the virtual interviews, the utility of the virtual format, their preferences, and the virtual resources they found the most helpful for determining their rank list. RESULTS: Of 72 applicants, 38 (18 women, 19 men, and 1 declined to answer) had completed the survey for a 57.2% response rate. The average number of programs interviewed was 25 to 30 (31%). More than one-half (55%) of the respondents had responded that they had interviewed at more programs than they would have had the interviews been in person. More than one-half of the applicants (55%) reported that they preferred remote interviews with the option to visit in-person at their top choice programs compared with the use of all remote interviews (21%) or all in-person interviews (18%). Most had somewhat or strongly agreed (79%) that virtual interviews allowed them to properly gauge a residency program and provided adequate opportunities to interact with the residents (65%). The online resources the applicants found the most helpful in determining their rank lists were attending educational conferences, prerecorded videos from faculty and residents, and the program's social media platforms. CONCLUSIONS: The results from the present study have illuminated the current trends and attitudes of I-VS applicants for virtual interviews, including the virtual resources they found the most useful. Virtual interviews were a preferred method of interviewing and allowed applicants to assess a residency program and interact with the current residents. These variables should be considered by the program leadership when developing protocols for upcoming application cycles.

Low Use of Outpatient Parenteral Antimicrobial Therapy for Drug Use-Associated Infective Endocarditis in an Urban Hospital System.

BACKGROUND: The opioid crisis in the United States has led to increasing hospitalizations for drug use-associated infective endocarditis (DUA-IE). Outpatient parenteral antimicrobial therapy (OPAT), the preferred modality for intravenous antibiotics for infective endocarditis, has demonstrated similar outcomes among patients with DUA-IE versus non-DUA-IE, but current studies suffer selection bias. The utilization of OPAT for DUA-IE more generally is not well studied. METHODS: This retrospective cohort study compared OPAT use for DUA-IE versus non-DUA-IE in adults hospitalized between January 1, 2015 and September 1, 2019 at 3 urban hospitals. We used multivariable regression analysis to assess the association between DUA-IE and discharge with OPAT, adjusting for clinically significant covariables. RESULTS: The cohort included 518 patients (126 DUA-IE, 392 non-DUA-IE). Compared to those with non-DUA-IE, DUA-IE patients were younger (53.0 vs 68.2 years, P < .001) and more commonly undomiciled (9.5% vs 0.3%, P < .01). Patients with DUA-IE had a significantly lower odds of discharge with OPAT than non-DUA-IE patients (adjusted odds ratio [aOR] = 0.20; 95% confidence interval [CI], 0.10-0.39). Odds of discharge with OPAT remained lower for patients with DUA-IE after excluding undomiciled patients (aOR = 0.22; 95% CI, 0.11-0.43) and those with patient-directed discharges (aOR = 0.27; 95% CI, 0.14-0.52). CONCLUSIONS: Significantly fewer patients with DUA-IE were discharged with OPAT compared to those with non-DUA-IE, and undomiciled patients or patient-directed discharges did not fully account for this difference. Efforts to increase OPAT utilization among patients with DUA-IE could have important benefits for patients and the healthcare system.