Institutional Transference in Serious Illness Care.

Institutional transference is a phenomenon describing patients' attitudes toward the institutions where they receive mental health or medical care. While transference toward individual clinicians in palliative care has been described, attitudes of patients with serious illness toward the institutions where they receive specialized care have not been described. Here, we present three cases which demonstrate the phenomenon of institutional transference in patients with serious illness and the resulting clinical implications, which include countertransferential responses of clinicians caring for them. We consider three conditions: (1) the idealized reputation of the academic cancer center, often a tertiary referral center; (2) loss of an institutional connection during care transitions; and (3) countertransferential reactions to institutional transference. We highlight characteristics and personality styles of individuals with cancer that may complicate and intensify institutional transference and identify potential interventions to address common challenges associated with institutional transference.

Disruption as an opportunity or threat: A qualitative analysis of factors influencing the attitudes of experts in serious illness care toward psychedelic-assisted therapies.

BACKGROUND: Psychedelic-assisted therapies (PAT) are emerging as a promising treatment for psycho-existential distress in patients with serious illness. A recent qualitative analysis of perspectives of 17 experts in serious illness care and/or PAT research identified divergent views on the therapeutic potential and safety of PAT in patients with serious illness. This paper further analyzes the factors that may influence these views. OBJECTIVES: To identify factors underlying the attitudes of experts in serious illness care and/or PAT toward PAT and its potential role in serious illness care. METHODS: Semi-structured interviews of 17 experts in serious illness care and/or PAT from the United States and Canada were analyzed to identify factors cited as influencing their views on PAT. RESULTS: Five factors were identified as influencing experts' attitudes toward PAT: perception of unmet need, knowledge of empirical studies of PAT, personal experience with psychedelics, professional background, and age/generation. In addition, an integrative theme emerged from the analysis, namely PAT's disruptive potential at 4 levels relevant to serious illness care: patient's experience of self, illness, and death; relationships with loved ones and health-care providers; existing clinical models of serious illness care; and societal attitudes toward death. Whether this disruptive potential was viewed as a therapeutic opportunity, or an undue risk, was central in influencing experts' level of support. Experts' perception of this disruptive potential was directly influenced by the 5 identified factors. SIGNIFICANCE OF RESULTS: Points of disruption potentially invoked by PAT in serious illness care highlight important practical and philosophical considerations when working to integrate PAT into serious illness care delivery in a safe and effective way.

A central role for R7bp in the regulation of itch sensation.

Itch is a protective sensation producing a desire to scratch. Pathologic itch can be a chronic symptom of illnesses such as uremia, cholestatic liver disease, neuropathies and dermatitis, however current therapeutic options are limited. Many types of cell surface receptors, including those present on cells in the skin, on sensory neurons and on neurons in the spinal cord, have been implicated in itch signaling. The role of G protein signaling in the regulation of pruriception is poorly understood. We identify here 2 G protein signaling components whose mutation impairs itch sensation. R7bp (a.k.a. Rgs7bp) is a palmitoylated membrane anchoring protein expressed in neurons that facilitates Gαi/o -directed GTPase activating protein activity mediated by the Gß5/R7-RGS complex. Knockout of R7bp diminishes scratching responses to multiple cutaneously applied and intrathecally-administered pruritogens in mice. Knock-in to mice of a GTPase activating protein-insensitive mutant of Gαo (Gnao1 G184S/+) produces a similar pruriceptive phenotype. The pruriceptive defect in R7bp knockout mice was rescued in double knockout mice also lacking Oprk1, encoding the G protein-coupled kappa-opioid receptor whose activation is known to inhibit itch sensation. In a model of atopic dermatitis (eczema), R7bp knockout mice showed diminished scratching behavior and enhanced sensitivity to kappa opioid agonists. Taken together, our results indicate that R7bp is a key regulator of itch sensation and suggest the potential targeting of R7bp-dependent GTPase activating protein activity as a novel therapeutic strategy for pathological itch.