Family Survey of Understanding and Communication of Patient Prognosis in the Intensive Care Unit: Identifying Training Opportunities.

OBJECTIVE: Family members making medical decisions for critically ill patients depend on surgeons' high-quality communication. We aimed to assess family experience of communication in the trauma intensive care unit (TICU), identify opportunities for improvement, and tailor resident communication training to address deficiencies. DESIGN: We designed surveys based on our Conceptual Model of Surgeon Communication and Family Understanding, using items from previously validated tools to assess (1) family well-being, experiences of care, access to information, and assessment of patient condition and prognosis; and (2) surgeon and nursing assessment of patient condition and prognosis. SETTING: Level I TICU in an independent academic medical center. PARTICIPANTS: Adult family members of patients hospitalized in the TICU > 24 hours; 88 families, 22 residents, 9 attendings, 81 nurses completed surveys on 78 unique patients. RESULTS: Family indicated: (1) they had easy access to medical information (91%); (2) the doctors (89%) and nurses (99%) listened carefully (p = 0.013); (3) they were included in morning rounds (80%); and (4) the doctors (91%) and nurses (98%) explained things well (p = 0.041). Family-surgeon agreement regarding the patient's condition and chance of cure was poor (28%) and fair (58%) respectively; families were typically more pessimistic than the surgeon regarding the patient's condition (65%), and more optimistic regarding chance of cure (26%). Residents cited mentors and skills practice with simulated patients as most influential training elements on communication style. CONCLUSIONS: Although families reported high-quality communication with the surgical team and rated physicians well in attributes related to trust, significant discordance in surgeon-family understanding of the patient's condition and prognosis persisted. This may be related to physician difficulty communicating complex information, or a family member's distress resulting in cognitive compromise, coupled with coping through hope and optimism. We recommend ongoing communication training for residents, skills practice for mentors, and open communication between nursing and physicians to optimize family information access.

Surgeon Communication and Family Understanding of Patient Prognosis in Critically Ill Surgical Patients: A Qualitative Investigation Informs Resident Training.

PURPOSE: Surgeons treating critically ill patients must work with family members making medical decisions for the patient. These surrogate decision makers depend on providers' high-quality communication and empathy to facilitate medical decisions. There is growing evidence of poor quality of communication and delayed family engagement in the intensive care unit, and of a decline in empathy over the course of a surgeon's clinical training. The aims of this study were to: (1) describe family understanding of patient prognosis among those admitted to our Trauma Intensive Care Unit (TICU), compared to the surgeon's assessment, and identify factors influencing the congruity of family-surgeon understanding ("congruence"); (2) characterize resident mentoring regarding difficult healthcare discussions and suggest adaptations to our communication program to address identified performance gaps. SETTING: Level I TICU in an independent academic medical center. METHODS: A qualitative research approach was valuable to discern the complexities of family understanding during highly stressful conditions. We enrolled adult family members of TICU patients, life expectancy <1 year, per attending. Using in-depth interviews we explored the family's experience with providers and the hospital system, and factors influencing understanding of the patient condition and decision making. We interviewed the surgical attending and/or resident separately to ascertain their perspective of the patient's condition and their experience with the family, as well as communication style, training, and influences on their approach. Interviews were audiotaped and transcribed. Using the systematic, multistep, rigorous coding process of grounded theory, we identified a range of experiences and common themes, and developed theories and hypotheses regarding factors influencing our outcomes of interest. RESULTS: We enrolled, coded, and analyzed 31 interviews from 16 cases; the data painted a broad description of a complex situation. We developed a conceptual model of our hypothesized factors influencing congruence (Figure). Our data suggest that congruence varies widely, and is influenced by family-surgeon engagement quality, information accessed from other hospital and personal sources, and, significantly, hospital system factors. Family-surgeon engagement quality is influenced by family and physician factors, case complexity, and myriad hospital factors. Both "physician factors" and "family factors" include previous experience, personal history, and beliefs, as well as dynamic factors such as current experiences and stress level. We identify several opportunities to improve congruence by adapting our resident communication training program: providing practice assessing family knowledge, expectations, and current understanding of information shared, and focusing on building trust. CONCLUSIONS: Surgical residents receive formal communication training and focused mentoring to gain important skills; however, family members' understanding of their loved one's critical condition is influenced by myriad hospital system factors beyond case complexity and surgeon communication skills.

USP7 Cooperates with NOTCH1 to Drive the Oncogenic Transcriptional Program in T-Cell Leukemia.

PURPOSE: T-cell acute lymphoblastic leukemia (T-ALL) is an aggressive disease, affecting children and adults. Chemotherapy treatments show high response rates but have debilitating effects and carry risk of relapse. Previous work implicated NOTCH1 and other oncogenes. However, direct inhibition of these pathways affects healthy tissues and cancer alike. Our goal in this work has been to identify enzymes active in T-ALL whose activity could be targeted for therapeutic purposes. EXPERIMENTAL DESIGN: To identify and characterize new NOTCH1 druggable partners in T-ALL, we coupled studies of the NOTCH1 interactome to expression analysis and a series of functional analyses in cell lines, patient samples, and xenograft models. RESULTS: We demonstrate that ubiquitin-specific protease 7 (USP7) interacts with NOTCH1 and controls leukemia growth by stabilizing the levels of NOTCH1 and JMJD3 histone demethylase. USP7 is highly expressed in T-ALL and is transcriptionally regulated by NOTCH1. In turn, USP7 controls NOTCH1 levels through deubiquitination. USP7 binds oncogenic targets and controls gene expression through stabilization of NOTCH1 and JMJD3 and ultimately H3K27me3 changes. We also show that USP7 and NOTCH1 bind T-ALL superenhancers, and inhibition of USP7 leads to a decrease of the transcriptional levels of NOTCH1 targets and significantly blocks T-ALL cell growth in vitro and in vivo. CONCLUSIONS: These results provide a new model for USP7 deubiquitinase activity through recruitment to oncogenic chromatin loci and regulation of both oncogenic transcription factors and chromatin marks to promote leukemia. Our studies also show that targeting USP7 inhibition could be a therapeutic strategy in aggressive leukemia.

Synthesis and Biological Investigation of Δ(12)-Prostaglandin J3 (Δ(12)-PGJ3) Analogues and Related Compounds.

A series of Δ(12)-prostaglandin J3 (Δ(12)-PGJ3) analogues and derivatives were synthesized employing an array of synthetic strategies developed specifically to render them readily available for biological investigations. The synthesized compounds were evaluated for their cytotoxicity against a number of cancer cell lines, revealing nanomolar potencies for a number of them against certain cancer cell lines. Four analogues (2, 11, 21, and 27) demonstrated inhibition of nuclear export through a covalent addition at Cys528 of the export receptor Crm1. One of these compounds (i.e., 11) is currently under evaluation as a potential drug candidate for the treatment of certain types of cancer. These studies culminated in useful and path-pointing structure-activity relationships (SARs) that provide guidance for further improvements in the biological/pharmacological profiles of compounds within this class.

Total Synthesis of Δ(12) -Prostaglandin J3 : Evolution of Synthetic Strategies to a Streamlined Process.

The total synthesis of Δ(12) -prostaglandin J3 (Δ(12) -PGJ3 , 1), a reported leukemia stem cell ablator, through a number of strategies and tactics is described. The signature cross-conjugated dienone structural motif of 1 was forged by an aldol reaction/dehydration sequence from key building blocks enone 13 and aldehyde 14, whose lone stereocenters were generated by an asymmetric Tsuji-Trost reaction and an asymmetric Mukaiyama aldol reaction, respectively. During this program, a substituent-governed regioselectivity pattern for the Rh-catalyzed C-H functionalization of cyclopentenes and related olefins was discovered. The evolution of the synthesis of 1 from the original strategy to the final streamlined process proceeded through improvements in the construction of both fragments 13 and 14, exploration of the chemistry of the hitherto underutilized chiral lactone synthon 57, and a diastereoselective alkylation of a cyclopentenone intermediate. The described chemistry sets the stage for large-scale production of Δ(12) -PGJ3 and designed analogues for further biological and pharmacological studies.

Synthesis of the diaryl ether cores common to chrysophaentins A, E and F.

The synthesis of the diaryl ether subunits of the marine natural products chrysophaentin A, E and F is described. These natural prodcuts feature tetrasubstituted benzene rings with complex substitution patterns. The central strategy involves an SNAr reaction between a complex phenol and a polysubstituted fluoronitrobenzene. Subseqent attempts to construct the unusual E-chloroalkene linkage through several different approaches are also disclosed.

Inhibitors of bacterial tubulin target bacterial membranes in vivo.

FtsZ is a homolog of eukaryotic tubulin that is widely conserved among bacteria and coordinates the assembly of the cell division machinery. FtsZ plays a central role in cell replication and is a target of interest for antibiotic development. Several FtsZ inhibitors have been reported. We characterized the mechanism of these compounds in bacteria and found that many of them disrupt the localization of membrane-associated proteins, including FtsZ, by reducing the transmembrane potential or perturbing membrane permeability. We tested whether the reported phenotypes of a broad collection of FtsZ inhibitors disrupt the transmembrane potential in Bacillus subtilis strain 168. Using a combination of flow cytometry and microscopy, we found that zantrin Z1, cinnamaldehyde, totarol, sanguinarine, and viriditoxin decreased the B. subtilis transmembrane potential or perturbed membrane permeability, and influenced the localization of the membrane-associated, division protein MinD. These studies demonstrate that small molecules that disrupt membrane function in bacterial cells produce phenotypes that are similar to the inhibition of proteins associated with membranes in vivo, including bacterial cytoskeleton homologs, such as FtsZ. The results provide a new dimension for consideration in the design and testing of inhibitors of bacterial targets that are membrane-associated and provide additional insight into the structural characteristics of antibiotics that disrupt the membrane.

Second-Generation Synthesis of (-)-Viriditoxin.

Viriditoxin is a secondary metabolite isolated from Aspergillus viridinutans that has been shown to inhibit FtsZ, the bacterial homologue of eukaryotic tubulin. A streamlined, scalable, and highly diastereoselective synthesis of this complex natural product is described. Key advances include a more efficient synthesis of the requisite unsaturated pyranone, scalable assembly of the naphthopyranone monomer, and improved diastereoselectivity in the biaryl-coupling reaction. In addition, we disclose a serendipitous ruthenium-catalyzed anion dimerization resulting from trace metal left by an RCM reaction.

Comparison of small molecule inhibitors of the bacterial cell division protein FtsZ and identification of a reliable cross-species inhibitor.

FtsZ is a guanosine triphosphatase (GTPase) that mediates cytokinesis in bacteria. FtsZ is homologous in structure to eukaryotic tubulin and polymerizes in a similar head-to-tail fashion. The study of tubulin's function in eukaryotic cells has benefited greatly from specific and potent small molecule inhibitors, including colchicine and taxol. Although many small molecule inhibitors of FtsZ have been reported, none has emerged as a generally useful probe for modulating bacterial cell division. With the goal of establishing a useful and reliable small molecule inhibitor of FtsZ, a broad biochemical cross-comparison of reported FtsZ inhibitors was undertaken. Several of these molecules, including phenolic natural products, are unselective inhibitors that seem to derive their activity from the formation of microscopic colloids or aggregates. Other compounds, including the natural product viriditoxin and the drug development candidate PC190723, exhibit no inhibition of GTPase activity using protocols in this work or under published conditions. Of the compounds studied, only zantrin Z3 exhibits good levels of inhibition, maintains activity under conditions that disrupt small molecule aggregates, and provides a platform for exploration of structure-activity relationships (SAR). Preliminary SAR studies have identified slight modifications to the two side chains of this structure that modulate the inhibitory activity of zantrin Z3. Collectively, these studies will help focus future investigations toward the establishment of probes for FtsZ that fill the roles of colchicine and taxol in studies of tubulin.

Synthesis of 6,6'-binaphthopyran-2-one natural products: pigmentosin A, talaroderxines A and B.

Efficient and stereoselective syntheses of pigmentosin A, talaroderxine A, and its diastereomer talaroderxine B are reported. The binaphthyl ring system is assembled by vanadium-catalyzed phenolic coupling of tricyclic precursors. These key intermediates were prepared by Michael-Dieckmann annulation of a protected orsellinate ester, with the requisite pyranones accessed by a new variant of Ghosez's sulfone-epoxide annulation. Preliminary biological experiments are reported for pigmentosin.