An innovative solution to raise public awareness using a mobile colorectal clinic - The 'bowel bus'.

INTRODUCTION: Colorectal cancer is the fourth most common cancer in the United Kingdom; however, figures show that the uptake for bowel cancer screening lags behind other cancer screening programmes. METHODS: This is a report of a multi-staged development of an outreach colorectal clinical community service provided through a Mobile Unit (a Bowel Bus). The unit delivers a one-stop colorectal clinic that provides a rapid access pathway to members of the public who have concerns about, or symptoms of, bowel cancer. The aims of the project were to increase public awareness about colorectal cancer and to provide an outreach clinic as a supplement to the hospital based colorectal clinic. This service is a result of collaborative efforts between Tenovus Cancer Care (TCC) and the colorectal surgery department of the local NHS Hospital. RESULTS: During one year, the Bowel Bus has provided services to 772 members of the local community. 244 patients were examined by the colorectal nurse specialist including 66 drop-in patients and 135 patients referred by the GPs. The service led to decrease in the waiting list for routine referrals to be seen in the colorectal clinic at the hospital from a mean of 10.5 weeks-5.9 weeks. A feedback questionnaire from 180 patients, used to audit the quality of the service, has confirmed an overwhelming satisfaction with the service. CONCLUSION: The Mobile Unit is a novel solution to addressing the ever increasing demand for specialist outpatient services without compromising the quality of care whilst enhancing the patient experience.

E-genetics: exploring the acceptability and feasibility of using technology in cancer genetics services.

The use of information and communication technologies (ICTs) in the delivery of cancer genetics services could improve equality of access in rural areas and help meet the increasing demand for specialist genetics services. An online patient survey and focus groups with patients and staff from the Cancer Genetics Service for Wales (CGSW) were used to explore the acceptability and feasibility of utilizing ICTs within genetics services, which we have termed e-genetics. A total of 225 patients completed the online survey. Many aspects of e-genetics proposed in the survey were highly acceptable to patients, including an electronic version of the family history questionnaire, an email facility for cancer genetic queries, and a computerized decision-aid. Participants in the focus groups emphasized the importance of patient choice when developing new models of service delivery. For example, the use of genetic counselling via telemedicine was not considered to be preferable to face-to-face clinic appointments but could benefit those unable to travel. This article highlights the fact that e-genetics initiatives may not be appropriate for all cancer genetics service users. However, user-friendly developments that can be easily implemented and attend to individual needs could improve efficiency and cost-effectiveness, whilst providing high-quality services to remote areas.

Patient perceptions of a mobile cancer support unit in South Wales.

Many patients have to travel long distances to receive treatment and support for cancer, which can lead to increased anxiety and fatigue. Tenovus, the cancer charity, working with the NHS, has developed a new concept of closer-to-home delivery for chemotherapy and other cancer support - a mobile cancer support unit (Bus). Researchers at Cardiff University evaluated the Bus during its first year of operation. The evaluation aimed to determine who was using the Bus and to explore patients' perceptions about having their appointments on the Bus. Data were collected from patients, social care clients and their family and friends using a mixed-methods approach. Quantitative data were collected using postal surveys and qualitative data were collected through semi-structured interviews. In its first year, 3487 people visited the Bus, which included the delivery of 549 chemotherapy treatments. Patient attitudes towards the Bus were extremely positive. Respondents rated highly key aspects of the Bus including comfort and the level of care provided. This evaluation demonstrates that all users are highly receptive to this model of service delivery and agree that the Tenovus Bus is a unique mobile unit, providing excellent clinical and social care to cancer patients and their families.

Interventions to improve risk communication in clinical genetics: systematic review.

OBJECTIVE: Effective risk communication may enable clients to participate effectively in decision-making about their health and health care. A systematic review of existing literature on risk communication in genetics, and its effects on key outcomes for clients, was undertaken. METHOD: Systematic searching of six electronic databases and data extraction from included studies; narrative synthesis of results. RESULTS: Twenty-eight studies were included, principally from cancer genetics. Sixteen communication interventions have been evaluated, generally showing improvements in cognitive outcomes for users, such as knowledge, understanding and risk perception, and without adverse effects on anxiety, cancer-related worry and depression. However, often it was the supportive or emotional elements of counselling that provided benefits to users, rather than the informational or educational elements. Similar results were found in 12 further studies of decision aids which also appear to achieve shorter consultations that can focus more on the supportive elements of counselling. CONCLUSION: For both communication models and decision aids, the supportive or emotional elements of counselling provided more benefits to users than the informational or educational elements. PRACTICE IMPLICATIONS: Debate is required on how to strike a balance between the medical model, its agenda and perceived requirements to disclose or discuss a range of issues and the sometimes competing goals of addressing users' concerns, needs for support, issues of loss and relationship problems.

Cancer genetic risk assessment for individuals at risk of familial breast cancer.

BACKGROUND: The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, resulting in the creation of genetics clinics for familial cancer. The first step for patients referred to a cancer genetic clinic is a risk assessment. OBJECTIVES: To evaluate the impact of cancer genetic risk assessment services on patients at risk of familial breast cancer. SEARCH STRATEGY: The specialised register maintained by the Cochrane Breast Cancer Group was searched. We also searched MEDLINE, EMBASE, CINAHL, PsycLIT, CENTRAL, DARE, ASSIA, Web of Science, SIGLE and LILACS. The searches covered the period 1985 to February 2005. We also hand-searched relevant journals. SELECTION CRITERIA: Trials looking at interventions for cancer genetic risk assessment delivery for familial breast cancer were considered for inclusion. Trials assessed outcomes such as understanding of risk, satisfaction and psychological well-being. Studies were excluded if they concerned cancers other than breast cancer or if participants were not at risk of breast cancer. Trials concerning the provision of information or education were also excluded as it was intended to review these separately. Participants could be individuals of any age or gender, with or without a known BRCA mutation, but without a previous history of breast cancer or any other serious illness. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Additional information was sought from investigators as necessary. Due to the heterogeneity of both the interventions and outcomes, data were analysed descriptively. MAIN RESULTS: Fifty-eight papers were identified as relevant to the review, 54 of these were subsequently excluded. The three included trials (pertaining to five papers), provide data on 1251 participants and assessed the impact of cancer genetic risk assessment on outcomes including perceived risk, and psychological distress. This review suggests that cancer genetic risk assessment services help to reduce distress, improve the accuracy of the perceived risk of, and increase knowledge about, breast cancer and genetics. The health professional delivering the risk assessment does not appear to have a significant impact on these outcomes. AUTHORS' CONCLUSIONS: This review found favourable outcomes for patients' risk assessment for familial breast cancer. However, there were too few papers to make any significant conclusions about how best to deliver cancer genetic risk assessment services. Further research is needed assessing the best means of delivering cancer risk assessment, by different health professionals, in different ways and in alternative locations.

Delivering information about cancer genetics via letter to patients at low and moderate risk of familial cancer: a pilot study in Wales.

Increasing demands upon specialist cancer genetics services have resulted in a need to explore alternative means of delivering genetic risk information to individuals at low-risk of familial cancer. This pilot study investigates patient satisfaction with a letter to low and moderate risk individuals notifying them of their risk. Sixty-six people completed a questionnaire designed to measure satisfaction with the way they had been notified of their cancer risk. Two key findings emerge from the data: first of all, whilst many respondents indicated overall satisfaction with the risk letter, a substantial number wanted more information about their risk; and secondly, low-risk individuals in this study are less reassured by and less satisfied with the risk letter than those at moderate risk. The optimal service provision for delivery of genetic risk information is likely to be one which can best respond to individual differences in information-seeking, distress and risk comprehension. There is a need therefore, for a randomised control trial to compare the effectiveness of a risk notification letter with more traditional telephone risk counselling and the implications of each mode of delivery upon the resources of specialist cancer genetics services.

Experiences of men with breast cancer: an exploratory focus group study.

Management and care of men with breast cancer is based on that developed for women. Our study reports that men have specific issues regarding certain aspects of their breast cancer experience, including diagnosis, disclosure, support and gender-specific information, and offers suggestions for improved patient care.

Developing a cancer genetics service in Wales: opinions of gynaecologists on the management of women at risk of familial ovarian cancer.

In Wales, a cancer genetics service has been developing since 1998. Gynaecologists play an integral role in the management of women with a family history of ovarian cancer and we were interested in investigating referral practice and management for relatives of patients with ovarian cancer among gynaecologists in Wales. In 1999, a postal questionnaire was sent to all gynaecologists. The response rate was 51%. The questionnaire contained structured questions about current provision and a number of hypothetical scenarios to explore referral patterns to the cancer genetics service. The results of this study showed that referrals varied widely among specialists, as did the numbers who required onward referral to cancer genetics. The offer of screening to women at high risk of ovarian cancer was consistent, although there were variations in how often it was offered and the age at which it was offered. Most gynaecologists were easily able to establish when it was appropriate to refer onwards to cancer genetics, differentiating between women at high or low risk. There was some confusion about women at moderate risk of ovarian cancer. This study demonstrated the need for clear referral guidelines in Wales. Guidelines have since been distributed to all general practitioners and specialists; however, continued monitoring and further evaluation of referral practices will be necessary.

Eugenics and its relevance to contemporary health care.

Recently there has been a revival of interest in the theory and practice of eugenics by both academics and lay people. The ongoing revolution in biology and the increasing ability to acquire genetic information has led to concerns about genetics being used again for sinister eugenic ends. Although the goals behind traditional eugenics--the minimization of disease and the improvement of human health--remain unchanged, the means by which these goals should be achieved have altered significantly. However, in debates about the impact of human genetic research, eugenics is sometimes viewed as a purely historical phenomenon and its relevance to the current situation is minimized. This article outlines the history of the eugenics movement, describes some eugenic practices, and explores why an appreciation of these historical debates is important for nurses.

The need to import skilled personnel: factors favouring and hindering its international mobility.

PIP: "Skilled migration has become a major element of contemporary flows.... The article [discusses] issues facing sending and receiving countries.... The article argues that the neo-classical view that skilled migration leads to overall improvement in global development does not apply. ¿Brain waste' or ¿wasted skills' occur frequently, to the detriment of both individuals and nations. Improved data and constructive dialogue on skilled migration are needed. Within both regional and international contexts, countries have obligations and responsibilities towards each other which need to be taken seriously." (EXCERPT)^ieng

Australian immigration between globalization and recession.

"This report has given some idea of the wide-ranging discussions at the Second National Immigration Outlook Conference [held in Sydney, Australia, in 1993], and of the way they reflect vital political, economic, and social issues in a country built upon mass immigration. The strains of globalization, geopolitical reorientation, and economic restructuring are having decisive effects on policies of immigration and multiculturalism. The consequences of such changes are difficult to predict, but in the authors' opinion they could lead to the breakdown of the 'Australian model' which has been remarkably successful in incorporating very large numbers of newcomers from varied backgrounds. The result might be considerable hardship and social tension."

Patterns of spouse/fiance sponsorship to Australia.

"This article is based on research conducted in 1992 for the [Australian] Department of Immigration and Ethnic Affairs. The aim was to investigate both repeat and serial sponsorship...for all groups of women, though the majority are from Asia. Interviews with women who had been sponsored, community and health workers, refuge workers and others revealed that repeat sponsorship was a common phenomenon. Further, repeat sponsors demonstrated a high level of perpetration of various forms of domestic violence."

Immigrant qualifications: recognition and relative wage outcomes.

"One aim of this study is to examine the labor market outcomes of immigrants relative to the Australian born.... In particular, this article examines both the extent of formal nonrecognition of overseas qualifications and the indirect implications for wage outcomes of a lack of full recognition of qualifications. Immigrant relative wage analysis...is the subject of the second part of this article...."

Barriers to migrant entry to occupations in Australia.

PIP: In 1986, 21.3% of the population of Australia had been born overseas; currently, foreign born workers comprise 25% of the labor force. The level of skilled immigration has continued to increase throughout the 1980s. In the past, most English-speaking migrants gained recognition of their overseas qualifications, but about half of those from non-English speaking countries have never been able to return to their pre-migration occupations. Beginning with the medical field, occupational regulating gradually grew with state autonomy being a marked feature. Australia has 1 of the most highly regulated labor markets in the world, with hundreds of bodies to determine entry criteria. The Council of Overseas Professional Qualifications, established in 1969, guides selection and tests professionals both overseas and already resident in Australia. The Tradesmen's Rights Regulation Act recognizes acceptable tradesmen. Aside from these 2 bodies, the majority of qualifications are assessed at the state or local level. Problems skilled immigrants have encountered in attempting to gain recognition of their overseas qualifications include 1) preference for locally trained workers or discrimination against non-British/non-Australian qualifications; 2) lack of adequate information about assessment procedures; 3) inadequate use of interpreting and translating services; 4) language difficulties in tests; and 5) frequent assessment only on formal qualifications, with skills and experience not being evaluated. The 2 basic models for assessing occupational suitability are the valuation of qualifications approach and the valuation of skills approach. To illustrate the operation of various models of assessment, the author discusses these occupations: medicine, nursing, engineering, computing, and electrical trades. The major factors that are essential for an overall strategy of change include 1) less occupational regulation in the labor market; 2) national registration and licensing systems in the "life-threatening" or "critical" occupations; 3) optional certification systems preferably at the national level, in the noncritical occupations; 4) skills-based assessments; 5) mainstreaming of all assessment mechanisms into authorized accrediting and assessing agencies; and 6) flexible means of entry to occupations. The establishment of an appropriate mechanism and legislation for achieving this change is of paramount importance.^ieng

Ontogenic development of the elastic component of the aortic wall in spontaneously hypertensive rats.

In the neonatal stage of development in spontaneously hypertensive rats (SHR), previous studies have shown that arterial pressure is already significantly increased over that of normotensive WKY controls and that other hypertensive characteristics of the cardiovascular system are also in evidence. The present study describes early development of the elastic component of the aortic wall in fetal (days 17, 19, 21-22 of gestation) and neonatal (days 1, 7, 14, 21 of age) SHR and WKY, to determine whether the early pattern of elastin accumulation differs significantly in hypertensive and normotensive animals. The data indicate that in SHR there is a greater concentration of elastin in the aortic wall, a larger cross-sectional area and an increase in the number of lamellar units, both pre- and postnatally. We conclude that the differences in arterial wall structure which are associated with genetic hypertension are established early in development.

Satietin: route of injection, dose response, effect on food and water intake and on running-wheel activity in the rat.

Semipurified satietin significantly (p less than 0.05) reduced food intake when injected subcutaneously at 10, 15, 20 mg/kg into 48 hr fasted rats with no indication of a dose response. When infused intracerebroventricularly (ICV) at 12.5, 25 and 50 micrograms/rat (10 microliter vol) into ad lib fed rats at the end of the light period there was no effect on food intake for the first hour but 24 hr food intake was (p less than 0.001) reduced at all doses. The ICV dose response curve was shallow, with similar suppression at both 12.5 and 25 micrograms doses, but a (p less than 0.05) greater suppression with the 50 micrograms dose. An ICV threshold between 6.25 micrograms and 12.5 micrograms appears to exist since no suppression occurred after a dose of 6.25 micrograms. Four consecutive daily ICV infusions of satietin (25 micrograms/rat) in two rats progressively suppressed food intake to low levels, suggesting a cumulative effect. Following termination of satietin treatment daily food intake slowly returned towards normal without evidence of rebound feeding. In other ad lib fed rats, four ICV infusions of semipurified satietin, on days alternated with no infusion, reduced food intake (p less than 0.001), water intake (p less than 0.003) and running wheel activity (p less than 0.001) on the first day of injection but not on subsequent injection days. Suppression of activity approached significance on the second injection day. Highly purified satietin infused ICV produced similar responses. These findings may indicate a general disruption of behavior by satietin, thus, it may not play a physiological role in feeding behavior because of its apparent non-specificity.