A toolkit for incorporating genetics into mainstream medical services: Learning from service development pilots in England.

BACKGROUND: As advances in genetics are becoming increasingly relevant to mainstream healthcare, a major challenge is to ensure that these are integrated appropriately into mainstream medical services. In 2003, the Department of Health for England announced the availability of start-up funding for ten 'Mainstreaming Genetics' pilot services to develop models to achieve this. METHODS: Multiple methods were used to explore the pilots' experiences of incorporating genetics which might inform the development of new services in the future. A workshop with project staff, an email questionnaire, interviews and a thematic analysis of pilot final reports were carried out. RESULTS: Seven themes relating to the integration of genetics into mainstream medical services were identified: planning services to incorporate genetics; the involvement of genetics departments; the establishment of roles incorporating genetic activities; identifying and involving stakeholders; the challenges of working across specialty boundaries; working with multiple healthcare organisations; and the importance of cultural awareness of genetic conditions. Pilots found that the planning phase often included the need to raise awareness of genetic conditions and services and that early consideration of organisational issues such as clinic location was essential. The formal involvement of genetics departments was crucial to success; benefits included provision of clinical and educational support for staff in new roles. Recruitment and retention for new roles outside usual career pathways sometimes proved difficult. Differences in specialties' working practices and working with multiple healthcare organisations also brought challenges such as the 'genetic approach' of working with families, incompatible record systems and different approaches to health professionals' autonomous practice. 'Practice points' have been collated into a Toolkit which includes resources from the pilots, including job descriptions and clinical tools. These can be customised for reuse by other services. CONCLUSIONS: Healthcare services need to translate advances in genetics into benefits for patients. Consideration of the issues presented here when incorporating genetics into mainstream medical services will help ensure that new service developments build on the body of experience gained by the pilots, to provide high quality services for patients with or at risk of genetic conditions.

Influence of the endothelium on ex vivo tolerance and metabolism of glyceryl trinitrate in rat aorta.

The influence of the endothelium on glyceryl trinitrate metabolism and relaxation and the relationship to tolerance induced by transdermal glyceryl trinitrate was explored in rat aorta. Metabolism was assessed in artery segments incubated with glyceryl trinitrate (1.0 microM) for 2 min and the contents of 1,2- and 1,3-glyceryl dinitrate measured by gas chromatography. In non-tolerant arteries mean contents of glyceryl trinitrate, 1,2-glyceryl dinitrate and 1,3-glyceryl dinitrate were 3.2, 0.23 and 0.10 nmol/g, respectively; in tolerant arteries the content of 1,2-glyceryl dinitrate was reduced by approximately 60%. Endothelium removal or nitric oxide synthase (NOS) inhibition did not affect metabolite contents but increased the relaxant response to glyceryl trinitrate in the tolerant artery to an extent that tolerance was significantly attenuated. It is concluded that (i) tolerance is associated with depression of glyceryl trinitrate metabolism by an endothelium-independent mechanism and (ii) the endothelium contributes to tolerance by a mechanism which is independent of metabolism and may be linked with endothelial NOS.