Enhancing legacy in palliative care: study protocol for a randomized controlled trial of Dignity Therapy focused on positive outcomes

BACKGROUND: Dignity Therapy is a brief psychotherapy that can enhance a sense of legacy while addressing the emotional and existential needs of patients receiving hospice or palliative care. In Dignity Therapy, patients create a formalized “legacy” document that records their most cherished memories, their lessons learned in life, as well as their hopes and dreams for loved ones in the future. To date, this treatment has been studied for its impact on mitigating distress within hospice and palliative care populations and has provided mixed results. This study will instead focus on whether Dignity Therapy enhances positive outcomes in this population. METHODS/DESIGN: In this study, 90 patients with cancer receiving hospice or palliative care will complete a mixed-methods randomized controlled trial of Dignity Therapy (n = 45) versus Supportive Attention (n = 45). The patients will be enrolled in the study for 3 weeks, receiving a total of six study visits. The primary outcomes examine whether the treatment will quantitatively increase levels of positive affect and a sense of life closure. Secondary outcomes focus on gratitude, hope, life satisfaction, meaning in life, resilience, and self-efficacy. Using a fixed, embedded dataset design, this study will additionally use qualitative interviews to explore patients’ perceptions regarding the use of positive outcome measures and whether these outcomes are appropriately matched to their experiences in therapy. DISCUSSION: Dignity Therapy has shown mixed results when evaluating its impact on distress, although no other study to date has solely focused on the potential positive aspects of this treatment. This study is novel in its use of mixed methods assessments to focus on positive outcomes, and will provide valuable information about patients’ direct experiences in this area. TRIAL REGISTRATION: ISRCTN9138919

Peptide Inhibitors of Dengue-Virus Entry Target a Late-Stage Fusion Intermediate

The mechanism of membrane fusion by “class II” viral fusion proteins follows a pathway that involves large-scale domain rearrangements of the envelope glycoprotein (E) and a transition from dimers to trimers. The rearrangement is believed to proceed by an outward rotation of the E ectodomain after loss of the dimer interface, followed by a reassociation into extended trimers. The ∼55-aa-residue, membrane proximal “stem” can then zip up along domain II, bringing together the transmembrane segments of the C-terminus and the fusion loops at the tip of domain II. We find that peptides derived from the stem of dengue-virus E bind stem-less E trimer, which models a conformational intermediate. In vitro assays demonstrate that these peptides specifically block viral fusion. The peptides inhibit infectivity with potency proportional to their affinity for the conformational intermediate, even when free peptide is removed from a preincubated inoculum before infecting cells. We conclude that peptides bind virions before attachment and are carried with virions into endosomes, the compartment in which acidification initiates fusion. Binding depends on particle dynamics, as there is no inhibition of infectivity if preincubation and separation are at 4°C rather than 37°C. We propose a two-step model for the mechanism of fusion inhibition. Targeting a viral entry pathway can be an effective way to block infection. Our data, which support and extend proposed mechanisms for how the E conformational change promotes membrane fusion, suggest strategies for inhibiting flavivirus entry

Beyond Continuity? Understanding Change in the UK Welfare State since 2010

One approach to identifying policy change stresses policy instruments, settings and policy paradigms, while another also considers the process and culmination of various shifts and consequent outcomes. This article illustrates the debate through an examination of how far developments in social security policy between the 1997–2010 New Labour and 2010–15 Coalition Governments in the UK constituted real policy shifts. It shows that, despite continuities in instruments and approach, there have been substantial changes in the impact of welfare state policies related to short-term benefits, employment and housing. The article identifies new policy directions leading to a different kind of welfare state, concerned less with living standards and equality and more with individual responsibility and paid work. It suggests that this has been achieved without the need for radical changes in instruments and their settings

Grifonin-1: A Small HIV-1 Entry Inhibitor Derived from the Algal Lectin, Griffithsin

Background: Griffithsin, a 121-residue protein isolated from a red algal Griffithsia sp., binds high mannose N-linked glycans of virus surface glycoproteins with extremely high affinity, a property that allows it to prevent the entry of primary isolates and laboratory strains of T- and M-tropic HIV-1. We used the sequence of a portion of griffithsin's sequence as a design template to create smaller peptides with antiviral and carbohydrate-binding properties. Methodology/Results: The new peptides derived from a trio of homologous β-sheet repeats that comprise the motifs responsible for its biological activity. Our most active antiviral peptide, grifonin-1 (GRFN-1), had an EC50 of 190.8±11.0 nM in in vitro TZM-bl assays and an EC50 of 546.6±66.1 nM in p24gag antigen release assays. GRFN-1 showed considerable structural plasticity, assuming different conformations in solvents that differed in polarity and hydrophobicity. Higher concentrations of GRFN-1 formed oligomers, based on intermolecular β-sheet interactions. Like its parent protein, GRFN-1 bound viral glycoproteins gp41 and gp120 via the N-linked glycans on their surface. Conclusion: Its substantial antiviral activity and low toxicity in vitro suggest that GRFN-1 and/or its derivatives may have therapeutic potential as topical and/or systemic agents directed against HIV-1

The co-evolution of policy mixes and socio-technical systems: towards a conceptual framework of policy mix feedback in sustainability transitions

Understanding how policymaking processes can influence the rate and direction of socio-technical change towards sustainability is an important, yet underexplored research agenda in the field of sustainability transitions. Some studies have sought to explain how individual policy instruments can influence transitions, and the politics surrounding this process. We argue that such individual policy instruments can cause wider feedback mechanisms that influence not only their own future development, but also other instruments in the same area. Consequently, by extending the scope of analysis to that of a policy mix allows us to account for multiple policy effects on socio-technical change and resultant feedback mechanisms influencing the policy processes that underpin further policy mix change. This paper takes a first step in this regard by combining policy studies and innovation studies literatures to conceptualise the co-evolutionary dynamics of policy mixes and socio-technical systems. We focus on policy processes to help explain how policy mixes influence socio-technical change, and how changes in the socio-technical system also shape the evolution of the policy mix. To do so we draw on insights from the policy feedback literature, and propose a novel conceptual framework. The framework highlights that policy mixes aiming to foster sustainability transitions need to be designed to create incentives for beneficiaries to mobilise further support, while overcoming a number of prevailing challenges which may undermine political support over time. In the paper, we illustrate the framework using the example of the zero carbon homes policy mix in the UK. We conclude with deriving research and policy implications for analysing and designing dynamic policy mixes for sustainability transitions

What facilitates the delivery of dignified care to older people? A survey of health care professionals Geriatrics

Background: Whilst the past decade has seen a growing emphasis placed upon ensuring dignity in the care of older people this policy objective is not being consistently achieved and there appears a gap between policy and practice. We need to understand how dignified care for older people is understood and delivered by the health and social care workforce and how organisational structures and policies can promote and facilitate, or hinder, the delivery of such care. Methods: To achieve our objective of understanding the facilitators and to the delivery of dignified care we undertook a survey with health and social care professionals across four NHS Trusts in England. Participants were asked provide free text answers identifying any facilitators/barriers to the provision of dignified care. Survey data was entered into SPSSv15 and analysed using descriptive statistics. These data provided the overall context describing staff attitudes and beliefs about dignity and the provision of dignified care. Qualitative data from the survey were transcribed verbatim and categorised into themes using thematic analysis. Results: 192 respondents were included in the analysis. 79 % of respondents identified factors within their working environment that helped them provide dignified care and 68 % identified barriers to achieving this policy objective. Facilitators and barriers to delivering dignified care were categorised into three domains: 'organisational level'; 'ward level' and 'individual level'. Within the these levels, respondents reported factors that both supported and hindered dignity in care including 'time', 'staffing levels', training',' 'ward environment', 'staff attitudes', 'support', 'involving family/carers', and 'reflection'. Conclusion: Facilitators and barriers to the delivery of dignity as perceived by health and social care professionals are multi-faceted and range from practical issues to interpersonal and training needs. Thus interventions to support health and social care professionals in delivering dignified care, need to take a range of issues into account to ensure that older people receive a high standard of care in NHS Trusts.Professor David Oliver, Professor Andree le May, Dr. Sally Richards, Dr Wendy Marti

Can national policy blockages accelerate the development of polycentric governance? Evidence from climate change policy in the United Kingdom

Many factors can conspire to limit the scope for policy development at the national level. In this paper, we consider whether blockages in national policy processes − resulting for example from austerity or small state political philosophies − might be overcome by the development of more polycentric governance arrangements. Drawing on evidence from three stakeholder workshops and fifteen interviews, we address this question by exploring the United Kingdom’s recent retrenchment in the area of climate change policy, and the ways in which its policy community have responded. We identify two broad strategies based on polycentric principles: ‘working with gatekeepers’ to unlock political capital and ‘collaborate to innovate’ to develop policy outputs. We then empirically examine the advantages that these actions bring, analysing coordination across overlapping sites of authority, such as those associated with international regimes, devolved administrations and civic and private initiatives that operate in conjunction with, and sometimes independently of, the state. Despite constraining political and economic factors, which are by no means unique to the UK, we find that a polycentric climate policy network can create opportunities for overcoming central government blockages. However, we also argue that the ambiguous role of the state in empowering but also in constraining such a network will determine whether a polycentric approach to climate policy and governance is genuinely additional and innovative, or whether it is merely a temporary ‘sticking plaster’ for the retreat of the state and policy retrenchment during austere times

Small-Molecule Inhibitors of Dengue-Virus Entry

Flavivirus envelope protein (E) mediates membrane fusion and viral entry from endosomes. A low-pH induced, dimer-to-trimer rearrangement and reconfiguration of the membrane-proximal “stem" of the E ectodomain draw together the viral and cellular membranes. We found stem-derived peptides from dengue virus (DV) bind stem-less E trimer and mimic the stem-reconfiguration step in the fusion pathway. We adapted this experiment as a high-throughput screen for small molecules that block peptide binding and thus may inhibit viral entry. A compound identified in this screen, 1662G07, and a number of its analogs reversibly inhibit DV infectivity. They do so by binding the prefusion, dimeric E on the virion surface, before adsorption to a cell. They also block viral fusion with liposomes. Structure-activity relationship studies have led to analogs with submicromolar IC90s against DV2, and certain analogs are active against DV serotypes 1,2, and 4. The compounds do not inhibit the closely related Kunjin virus. We propose that they bind in a previously identified, E-protein pocket, exposed on the virion surface and although this pocket is closed in the postfusion trimer, its mouth is fully accessible. Examination of the E-trimer coordinates (PDB 1OK8) shows that conformational fluctuations around the hinge could open the pocket without dissociating the trimer or otherwise generating molecular collisions. We propose that compounds such as 1662G07 trap the sE trimer in a “pocket-open" state, which has lost affinity for the stem peptide and cannot support the final “zipping up" of the stem