The Silent Threat: Bartonella quintana Endocarditis Unveiling Heart Failure and Severe Pulmonary Hypertension.

BACKGROUND Bartonella quintana is a slow-growing gram-negative bacterium that can cause severe culture-negative endocarditis. In many cases, its insidious onset can be difficult to diagnose given the variable symptoms in the early phases of the disease. This delay in detection and thus treatment can cause advanced consequences of the disease, including heart failure and severe pulmonary hypertension. CASE REPORT A 51-year-old man presented to the Emergency Department with signs and symptoms indicating an acute stroke. Further investigation showed that the source was cardioembolic, and despite negative blood cultures, endocarditis was suspected due to echocardiogram findings. Bartonella endocarditis was diagnosed based on serology results. Further testing indicated severe pulmonary hypertension, a sequelae of chronic heart failure in the setting of endocarditis. This caused a significant delay in valvular repair surgery. This case illustrates the progression from acute to chronic infection, the sequelae of this disease process, and the considerations involved in management. CONCLUSIONS Bartonella is an under-appreciated cause of endocarditis and can evolve into chronic disease with clinical consequences requiring nuanced management. We described a case of chronic culture-negative endocarditis that presented with acute embolic stroke and the sequelae of severe multi-valvular disease in a patient with recent incarceration and unstable housing. This case provides clinicians with valuable insight into the recognition of Bartonella endocarditis, the variable clinical presentations of this pathology, the nuanced and multifactorial approaches to medical management, and the indications for surgery.

Mobile Clinical Trial Matching Technology in Medical Oncology Clinic: A Pilot Feasibility Study.

PURPOSE: The internet is a common source of health information for patients and can be leveraged to provide patient-facing clinical trial information. This pilot study integrated an online prostate cancer clinical trial matching technology, called Trial Library (TL), in an academic medical oncology clinic from February 2019 to April 2021. PATIENTS AND METHODS: This is a single-arm interventional pilot study among patients with a known prostate cancer diagnosis. Participants were given access to TL before seeing a provider. The primary and secondary study end points were the overall satisfaction with TL and the proportion of participant-initiated clinical trial discussion with providers after exposure to TL, respectively. The null hypothesis or true satisfaction rate (acceptability) was tested against a one-sided alternative and was rejected if 29 or more satisfactions were observed. RESULTS: Among 272 patients approached, 66 provided informed consent to participate in the study. The mean age was 70.8 years (standard deviation = 7.9). The majority of participants were White (82%) and had metastases present at the time of enrollment (65%). The baseline clinical trial discussion rate ascertained via electronic medical record review was 28%. After accessing TL, a significantly larger proportion of participants (48.5%) discussed clinical trials during the clinic visit (P = .007), half of which were patient-initiated. The majority of participants indicated that TL increased their interest in clinical trials (68.2%); however, satisfaction/extreme satisfaction with the technology was 38%. CONCLUSION: Access to TL resulted in a significant increase in patient-initiated discussions regarding clinical trials and an increase in interest in clinical trial participation although these data do not address if this resulted in increased accrual to clinical trials. The satisfaction rate did not meet the target to reject the null hypothesis, suggesting the need for iterative design of patient-facing health information.

Surrogate Decision Makers Need Better Preparation for Their Role: Advice from Experienced Surrogates.

Background: Surrogate decision makers are required to make difficult end-of-life decisions with little preparation. Little is known about what surrogates may need to adequately prepare for their role, and few resources exist to prepare them. Objective: To explore experiences and advice from surrogates about how best to prepare for the surrogate role. Design: Semistructured focus groups. Setting/Participants: Sixty-nine participants were recruited through convenience sampling in San Francisco area hospitals, cancer support groups, and community centers for 13 focus groups. Surrogates were included if they were 18 years of age or older and reported having made medical decisions for others. Measurements: Qualitative thematic content analysis. Results: Forty participants reported making surrogate decisions for others: 6 were Spanish speaking, 22 were women, 16 were Black American, 11 Asian/Pacific Islander, 6 Latinx, and 7 White; 9 had limited health literacy. The majority (29, 73%) emphasized the importance of advance care planning (ACP) and expressed the desire for additional guidance. Five themes and advice were identified: (1) lack of, but needing, surrogates' own preparation and guidance (2) initiate ACP conversations, (3) learn patient's values and preferences, (4) communicate with clinicians and advocate for patients, and (5) make informed surrogate decisions. Conclusion: Experienced surrogate decision makers emphasized the importance of ACP and advised that surrogates need their own preparation to initiate ACP conversations, learn patients' values, advocate for patients, and make informed surrogate decisions. Future interventions should address these preparation topics to ease surrogate burden and decrease disparities in surrogate decision making.

A step towards equitable clinical trial recruitment: a protocol for the development and preliminary testing of an online prostate cancer health information and clinical trial matching tool.

BACKGROUND: Recruitment of a diverse participant pool to cancer clinical trials is an essential component of clinical research as it improves the generalizability of findings. Investigating and piloting novel recruitment strategies that take advantage of ubiquitous digital technologies has become an important component of facilitating broad recruitment and addressing inequities in clinical trial participation. Equitable and inclusive recruitment improves generalizability of clinical trial outcomes, benefiting patients, clinicians, and the research community. The increasing prevalence of online connectivity in the USA and use of the Internet as a resource for medical information provides an opportunity for digital recruitment strategies in cancer clinical trials. This study aims to measure the acceptability, preliminary estimates of efficacy, and feasibility of the Trial Library intervention, an Internet-based cancer clinical trial matching tool. This study will also examine the extent to which the Trial Library website, designed to address the linguistic and literacy needs of broader patient populations, influences patient-initiated conversations with physicians about clinical trial participation. METHODS: This is a study protocol for a non-randomized, single-arm pilot study. This is a mixed methods study design that utilizes the statistical analysis of quantitative survey data and the qualitative analysis of interview data to assess the participant experience with the Trial Library intervention. This study will examine (1) acceptability as a measure of participant satisfaction with this intervention, (2) preliminary measure of efficacy as a measure of proportion of participants with documented clinical trial discussion in the electronic medical record, and (3) feasibility of the intervention as a measure of duration of clinical visit. DISCUSSION: The principles that informed the design of the Trial Library intervention aim to be generalizable to clinical trials across many disease contexts. From the ground up, this intervention is built to be inclusive of the linguistic, literacy, and technological needs of underrepresented patient populations. This study will collect essential preliminary data prior to a multi-site randomized clinical trial of the Trial Library intervention. TRIAL REGISTRATION: This study has received institutional approval from the Committee of Human Subjects Research at the University of California, San Francisco.

Carbocyclic pyrimidine nucleosides as inhibitors of S-adenosylhomocysteine hydrolase.

The design, synthesis, and unexpected inhibitory activity against S-adenosyl-homocysteine (SAH) hydrolase (SAHase, EC 3.3.1.1) for a series of truncated carbocyclic pyrimidine nucleoside analogues is presented. Of the four nucleosides obtained, 10 was found to be active with a Ki value of 5.0 microM against SAHase.