"It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care.

Background: Healthcare fragmentation and lack of care coordination are longstanding problems in cancer care. This study's goal was to provide in-depth understanding of how the organization and fragmentation of healthcare impacts the experiences of patients with advanced cancer and their families, especially near the end-of-life.

Methods: This mixed-methods quality improvement study took place at a large multi-specialty healthcare organization in Northern California.

Biomolecule-Interactive Flexible Light Emitting Capacitor Display.

Ultrathin, lightweight, flexible, and conformable interactive displays that transduce external stimuli into human-readable signals are essential for emerging applications, such as wearable electronics, human-machine interfaces, and soft robots. Herein, a biomolecule-interactive flexible light emitting capacitor (LEC) display (BIO-LEC) capable of dynamic and quantitative visualization of biomolecules through naked-eye detectable electroluminescence (EL) emission is reported. BIO-LEC comprises a coplanar LEC light source at the bottom, and a designed microfluidic chip as sampling compartment at the top.

Evolving Goals of Care Discussions as Described in Interviews With Individuals With Advanced Cancer and Oncology and Palliative Care Teams.

Background: Individuals with advanced cancer and their families have negative end-of-life experiences when the care they receive is not aligned with their values and preferences.

Objective: To obtain in-depth information on how patients with advanced cancer and the oncology and palliative care (PC) clinicians who care for them discuss goals of care (GoC).

Design: The research team conducted in-depth interviews and qualitative data analysis using open coding to identify how perspectives on GoC discussions vary by stage of illness, and experience with PC teams.

How, when, and why individuals with stage IV cancer seen in an outpatient setting are referred to palliative care: a mixed methods study.

Purpose: Early palliative care (PC) for individuals with advanced cancer improves patient and family outcomes and experience. However, it is unknown when, why, and how in an outpatient setting individuals with stage IV cancer are referred to PC.

Methods: At a large multi-specialty group in the USA with outpatient PC implemented beginning in 2011, clinical records were used to identify adults diagnosed with stage IV cancer after January 1, 2012 and deceased by December 31, 2017 and their PC referrals and hospice use.

Rapid De-Escalation and Triaging Patients in Community-Based Palliative Care.

Context: The coronavirus disease 2019 (COVID-19) pandemic created a rapid and unprecedented shift in our medical system. Medical providers, teams, and organizations have needed to shift their visits away from face-to-face visits and toward telehealth (both by phone and through video). Palliative care teams who practice in the community setting are faced with a difficult task: How do we actively triage the most urgent visits while keeping our vulnerable patients safe from the pandemic?

Measures: The following are recommendations created by the Palo Alto Medical Foundation Palliative Care and Support Services team to help triage and coordinate for timely, safe, and effective palliative care in the community and outpatient setting during the ongoing COVID-19 pandemic.

Extended dual antiplatelet therapy for Asian patients with acute coronary syndrome: expert recommendations.

Background: Recently, new evidence from large scale trials and updated guidelines have emerged on the risks and benefits of extended dual antiplatelet therapy (DAPT) for patients with acute coronary syndrome (ACS).

Aims: To discuss, clarify and advise on the application of the evidences and guidelines on individual patient selection for extended DAPT, with regard to balancing risk factors, particularly in Asian populations.

Methods: A total of 14 local cardiologists from Hong Kong with extensive experience in cardiology and cardiac interventions convened in a series of 3 advisory board meetings from October 2016 to September 2017, which included reviews of new evidence in the literature and discussions of the latest clinical trends, using an anonymous, electronic voting system for arriving at consensuses.

Community-Based Palliative Care and Advance Care Planning Documentation: Evidence from a Multispecialty Group.

Background/objectives: With the growing public demand for access to critical health data across care settings, it is essential that advance care planning (ACP) information be included in the electronic health record (EHR) so that multiple clinicians can access it and understand individuals' preferences for end-of-life care. Community-based palliative care programs often incorporate ACP services. This study examined whether a community-based palliative care program is associated with digitally extractable ACP documentation in the EHR.

Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health-Care Directives and Physician Orders for Life-Sustaining Treatment.

Context: Advance care planning (ACP) is valued by patients and clinicians, yet documenting ACP in an accessible manner is problematic.

Objectives: In order to understand how providers incorporate electronic health record (EHR) ACP documentation into clinical practice, we interviewed providers in primary care and specialty departments about ACP practices (n = 13) and analyzed EHR data on 358 primary care providers (PCPs) and 79 specialists at a large multispecialty group practice.

Methods: Structured interviews were conducted with 13 providers with high and low rates of ACP documentation in primary care, oncology, pulmonology, and cardiology departments.

Multiple locations of advance care planning documentation in an electronic health record: are they easy to find?

Background: The ambulatory care setting is a new frontier for advance care planning (ACP). While electronic health records (EHR) have been expected to make ACP documentation more retrievable, the literature is silent on the locations of ACP documentation in EHRs and how readily they can be found.

Objective: The study's objective is to identify the locations of ACP documentation in EpicCare EHR and to determine which patient and primary care provider (PCP) characteristics are associated with having a scanned ACP document.

Treadmill scores in elderly men.

Objectives: This study seeks to further characterize the role of exercise testing in the elderly for prognosis and diagnosis of coronary artery disease.

Background: Recent exercise testing guidelines have recognized that statements regarding the elderly do not have an adequate evidence-based quality because the studies they are based on have limitations in sample size and design. The Duke Treadmill Score has been recommended for risk stratification, but recent evidence has suggested that it does not function in the elderly.

Mechanism of immediate recurrences of atrial fibrillation after restoration of sinus rhythm.

An immediate recurrence of AF may occur after restoration of sinus rhythm. Although pulmonary vein (PV) isolation has been shown to prevent immediate recurrence of AF, the specific trigger for immediate recurrence of AF has not been described. In 89 consecutive patients (mean age 53 +/- 11 years) who had sinus rhythm restored by spontaneous or transthoracic cardioversion in the course of a PV isolation procedure, electrograms recorded within a PV and in the adjacent left atrium were analyzed to determine the mechanism of initiation of immediate recurrence of AF.

Atrial electrogram amplitude and efficacy of cavotricuspid isthmus ablation for atrial flutter.

Large atrial electrogram amplitudes recorded in the cavotricuspid isthmus (CTI) may reflect thick atrial musculature. For this reason, in patients with atrial flutter, the efficacy of an application of conventional radiofrequency energy may be related to the amplitude of the local atrial electrogram. In 100 consecutive patients (mean age 59 +/- 13 years) with atrial flutter, contiguous applications of radiofrequency energy were delivered in the CTI.

Effect of atrial fibrillation duration on probability of immediate recurrence after transthoracic cardioversion.

Introduction: An immediate recurrence of atrial fibrillation (IRAF) appears to be more common after early restoration of sinus rhythm with an implantable atrial defibrillator than after elective transthoracic cardioversion, which suggests that the probability of IRAF may be related to the duration of AF.

Methods And Results: Transthoracic cardioversion was performed 85 +/- 187 days (range 7 minutes to 8 years) after the onset of atrial fibrillation in 315 patients (mean age 61 +/- 13 years). IRAF was defined as a recurrence of AF within 60 seconds after restoration of sinus rhythm.

Anatomy of the pulmonary veins in patients with atrial fibrillation and effects of segmental ostial ablation analyzed by computed tomography.

Introduction: The anatomic arrangement of pulmonary veins (PVs) is variable. No prior studies have quantitatively analyzed the effects of segmental ostial ablation on the PVs. The aim of this study was to determine the effect of segmental ostial radiofrequency ablation on PV anatomy in patients with atrial fibrillation (AF).

Effects of operator experience on the outcome and duration of pulmonary vein isolation procedures for atrial fibrillation.

Segmental, ostial ablation to isolate the pulmonary veins has been shown to be effective for the treatment of atrial fibrillation (AF). The purpose of this study was to determine the effects of operator experience on the outcome and duration of pulmonary vein isolation procedures for AF. One hundred three consecutive patients with AF underwent segmental, ostial ablation to isolate pulmonary veins.

Segmental ostial ablation to isolate the pulmonary veins during atrial fibrillation: feasibility and mechanistic insights.

Background: The purpose of this study was to determine the feasibility and mechanistic implications of segmental pulmonary vein (PV) ostial ablation during atrial fibrillation (AF).

Methods And Results: Forty consecutive patients underwent PV isolation for AF. Among 125 PVs targeted for isolation, ablation was performed during AF in 70 veins and during sinus rhythm in 55 veins.

Comparison of amiodarone versus ibutilide for the prevention of immediate recurrences of atrial fibrillation during pulmonary vein isolation.

During segmental ostial ablation for pulmonary vein isolation, pulmonary vein potentials are easily identified during sinus rhythm or left atrial pacing. Therefore, maintenance of atrial fibrillation (AF) during the procedure is desirable. However, cardioversion is occasionally followed by an immediate recurrence of AF.

Mechanistic significance of intermittent pulmonary vein tachycardia in patients with atrial fibrillation.

Introduction: The significance of intermittent tachycardia within a pulmonary vein (PV) during an episode of atrial fibrillation (AF) is unclear. The aim of this study was to determine the role that intermittent PV tachycardias play in AF.

Methods And Results: In 56 patients with AF, segmental ostial ablation guided by PV potentials was performed to isolate the PVs.

Clinical significance of early recurrences of atrial fibrillation after pulmonary vein isolation.

Objectives: The purposes of this study were to describe the prevalence of early recurrences of atrial fibrillation (ERAF) that occur within two weeks after pulmonary vein (PV) isolation, and to determine whether ERAF is predictive of long-term outcome after PV isolation.

Background: Atrial fibrillation (AF) sometimes recurs within days after PV isolation and may prompt an early repeat intervention.

Methods: Segmental PV isolation was performed using radiofrequency energy in 110 consecutive patients (mean age 53 +/- 11 years) with paroxysmal (93 patients) or persistent (17 patients) AF.

Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation.

Background: The pulmonary veins (PVs) have been demonstrated to often play an important role in generating atrial fibrillation (AF). The purpose of this study was to determine the safety and efficacy of segmental PV isolation in patients with paroxysmal or persistent AF.

Methods And Results: In 70 consecutive patients (mean age, 53 +/- 11 years) with paroxysmal (58) or persistent (12) AF, segmental PV isolation guided by ostial PV potentials was performed.