Twelve tips for designing and implementing an academic coaching program.

Coaching has become increasingly popular as a mechanism to support learning across the health professions education (HPE) continuum. While there is a growing body of literature in this area, there is minimal guidance related to the design and implementation of academic coaching in health professional courses. This paper seeks to contribute to this literature by presenting guidance for academic developers who are considering introducing academic coaching into a health professional course. The 12 tips are based on the authors' collective experiences of designing and implementing academic coaching in university medical courses in Australia and the UK. Although focused on medical education, this paper is intended to have applicability across the health professions, and potentially across university and postgraduate training contexts. Together, the tips offer a strategic and operational framework to guide the design and implementation of academic coaching initiatives in health professions education.

Association of primary and community care services with emergency visits and hospital admissions at the end of life in people with cancer: a retrospective cohort study.

OBJECTIVE: To examine the association between primary and community care use and measures of acute hospital use in people with cancer at the end of life. DESIGN: Retrospective cohort study. SETTING: We used Discover, a linked administrative and clinical data set from general practices, community and hospital records in North West London (UK). PARTICIPANTS: People registered in general practices, with a diagnosis of cancer who died between 2016 and 2019. PRIMARY AND SECONDARY OUTCOME MEASURES: ≥3 hospital admissions during the last 90 days, ≥1 admissions in the last 30 days and ≥1 emergency department (ED) visit in the last 2 weeks of life. RESULTS: Of 3581 people, 490 (13.7%) had ≥3 admissions in last 90 days, 1640 (45.8%) had ≥1 admission in the last 30 days, 1042 (28.6%) had ≥1 ED visits in the last 2 weeks; 1069 (29.9%) had more than one of these indicators. Contacts with community nurses in the last 3 months (≥13 vs <4) were associated with fewer admissions in the last 30 days (risk ratio (RR) 0.88, 95% CI 0.90 to 0.98) and ED visits in the last 2 weeks of life (RR 0.79, 95% CI 0.68 to 0.92). Contacts with general practitioners in the last 3 months (≥11 vs <4) was associated with higher risk of ≥3 admissions in the last 90 days (RR 1.63, 95% CI 1.33 to 1.99) and ED visits in the last 2 weeks of life (RR 1.27, 95% CI 1.10 to 1.47). CONCLUSIONS: Expanding community nursing could reduce acute hospital use at the end of life and improve quality of care.

Activation and regulation of toll-like receptor 9: CpGs and beyond.

Toll-like receptor 9 has been the focus of considerable research attention for the ability to modulate its activity, and subsequent innate immune responses, through DNA-based immunotherapeutics. Nucleic acids are attractive as therapeutics for their low cost, chemical stability and ease of production. While the ability for TLR9 to be differentially regulated by nucleic acids of varying sequences and structures offers flexibility for immunotherapeutic design, it also necessitates a more comprehensive characterization of these agonists in terms of how these structural parameters correlate with the activation of unique cellular responses. Despite the utilization of TLR9 agonists in human trials these issues have not been adequately addressed. While a wealth of cell stimulation experiments demonstrate the preferential ability for nucleic acids which contain unmethylated cytosine-phosphate-guanine (CpG) motifs to initiate innate immune responses this has not been supported by binding investigations from which largely contradictory information has emerged with respect to the ability of TLR9 to bind nucleic acids in a sequence-dependent fashion. Recent models help to reconcile this apparent contradiction by suggesting that while TLR9 activation is specific for CpG-containing nucleic acids, the receptor binds, and is functionally influenced by, nucleic acids in a sequence-independent fashion. We have proposed a model in which the absolute concentration of nucleic acids modulates the sensitivity of the receptor in a sequence-dependent fashion while activation is specifically achieved by CpG-containing ligands. In this review we reconsider the literature from the perspective of this new appreciation of the functional complexity of TLR9 ligand binding and higher-order regulation with discussion of the implications for immunotherapeutic targeting of TLR9.

The S-LANSS score for identifying pain of predominantly neuropathic origin: validation for use in clinical and postal research.

This article describes the development and validation of the S-LANSS score, a self-report version of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale. The S-LANSS aims to identify pain of predominantly neuropathic origin, as distinct from nociceptive pain, without the need for clinical examination. Two hundred patients with chronic pain were asked to complete the S-LANSS unaided. A researcher then administered the S-LANSS scale and the Neuropathic Pain Scale (NPS) in interview format. An independent clinician determined the pain type (neuropathic versus nociceptive) and rated his or her certainty about diagnosis. The S-LANSS scale was also incorporated into a chronic pain questionnaire that was sent to 160 community patients and 150 newly referred patients waiting for pain clinic assessment. The S-LANSS scale correctly identified 75% of pain types when self-completed and 80% when used in interview format. Sensitivity for self-completed S-LANSS scores ranged from 74% to 78%, depending on the cutoff score. There were significant associations between NPS items and total score with S-LANSS score. In the postal survey, completed questionnaires were returned by 57% of patients (n = 174). Internal consistency and convergent validity of the survey S-LANSS scores were confirmed. The findings support the S-LANSS scale as a valid and reliable self-report instrument for identifying neuropathic pain and it is also acceptable for use in postal survey research. Establishing valid measures of symptoms and signs in neuropathic pain will allow standardized comparisons with other investigational measures. This might lead to new insights into the relationship between pathophysiologic mechanisms and clinical manifestations of pain.

Pain experienced by lung cancer patients: a review of prevalence, causes and pathophysiology.

BACKGROUND: Lung cancer is one of the commonest cancers to cause pain, but little is known regarding the extent of this complex problem in these patients. METHODS: Medline (1966-June 2002) and Cancerlit (1975-May 2002) were searched to identify studies of lung cancer patients' experience of pain, its prevalence, causes and underlying pathophysiology. RESULTS: Thirty-two studies were identified. Patients were recruited from diverse populations, and the prevalence varied according to study setting. Pain affected 27% of outpatients (range 8-85%), and 76% of patients cared for by palliative care services (range 63-88%). Pain was caused by cancer in 73% (range 44-87%), and cancer treatment in 11% (range 5-17%). Nociceptive pain was the major pathophysiological subtype in lung cancer pain, but neuropathic pain accounted for 30% (range 25-32%) of cases. CONCLUSIONS: The overall weighted mean pain prevalence of pain was 47% (range 6-100%). Cancer patients should be asked about pain at all stages of management. Those with pain should be investigated for disease progression and considered for referral for specialist management.

Identifying neuropathic pain in patients with head and neck cancer: use of the Leeds Assessment of Neuropathic Symptoms and Signs Scale.

The Leeds Assessment of Neuropathic Symptoms and Signs Scale (LANSS) is a simple bedside test in two parts-a patient-completed questionnaire and a brief clinical assessment. Its diagnostic capabilities have never been tested in patients with cancer pain. To determine these we conducted a prospective study in outpatients with head and neck cancer. All patients with pain completed the LANSS and underwent a medical assessment with a palliative care physician, whose findings were then reviewed by a pain specialist blinded to the LANSS scores. We assessed acceptability and understanding of the LANSS by patients and calculated the sensitivity and specificity of total LANSS scores and subscores derived from the patient-completed section. Of 130 patients approached, 125 took part. 25 (20%) of these had cancer related pain, mean score on an 11 point numerical rating scale 6.3 (median 6.0, range 3-10). Average age was 60 years (median 60, range 27-84); 56% were male. LANSS completion time was about five minutes, and the procedure was acceptable to all patients. The pain specialist diagnosed neuropathic pain in 14/25 patients, in 13 of whom the neuropathic pain was part of a mixed pain picture. The LANSS correctly identified 11 of these cases (sensitivity 79%; specificity 100%). The patient-completed section alone had a sensitivity of 86% and a specificity of 91%. The LANSS is a simple and suitable screening test for neuropathic pain in patients with head and neck cancer related pain, although some modifications might improve it.

Nucleic acids exert a sequence-independent cooperative effect on sequence-dependent activation of Toll-like receptor 9.

Toll-like receptor 9 (TLR9) activates the innate immune system in response to microbial DNA or mimicking oligodeoxynucleotides. Although cell stimulation experiments demonstrate the preferential activation of TLR9 by CpG-containing nucleic acids, direct binding investigations have reached contradictory conclusions with respect to the ability of this receptor to bind nucleic acids in a sequence-specific manner. To address this apparent discrepancy, we report the purification of the soluble ectodomain of human TLR9 with characterization of its ligand binding properties. We observe that TLR9 has a high degree of specificity in its ability to bind nucleic acids that contain CpG dinucleotides as well as higher order motifs that mediate species-specific activation. However, TLR9 is also functionally influenced by nucleic acids in a sequence-independent fashion as both stimulatory and nonstimulatory nucleic acids sensitize TLR9 for in vitro ligand binding as well as in vivo activation. We propose a model in which receptor activation is achieved in a sequence-dependent manner, and sensitivity is modulated by the absolute concentration of nucleic acids in a sequence-independent fashion. This model bears resemblance to that recently proposed for Toll in that activation is a two-step process in which formation of a ligand-bound monomer precedes formation of the activated dimer. In each model receptor sensitivity is determined within the second step with the crucial distinction that Toll undergoes negative cooperativity, whereas TLR9 is sensitized through a positive cooperative effect.

Symptoms in 400 patients referred to palliative care services: prevalence and patterns.

The demographics and prevalence of symptoms in patients at first referral to the different components of palliative care services were identified by a retrospective case note study of 400 patients referred to three palliative care centres in London, UK: Michael Sobell House, Mount Vernon Hospital; The North London Hospice; St Bartholomew's and the Royal London Hospitals. One hundred consecutive referrals to each of the following service components were analysed: a hospice inpatient service; a community team; an NHS hospital support team and an outpatient service. A standardized proforma was used to collect the data. Ninety five per cent (380/400) of patients referred had a cancer diagnosis. The five most prevalent symptoms overall were pain (64%), anorexia (34%), constipation (32%), weakness (32%) and dyspnoea (31%), which is similar to other published reports. However, the commonest symptoms and their prevalence varied depending on the service component to which the patient was referred. Patients referred to hospice and community services had the highest symptom burden (mean number of symptoms per patient 7.21 and 7.13, respectively). This study suggests that different patient subgroups may have different needs in terms of symptoms, which will be relevant for the planning and rationalization of palliative care services.