Do national policies for complaint handling in English hospitals support quality improvement? Lessons from a case study.

OBJECTIVES: A range of public inquiries in the English National Health Service have indicated repeating failings in complaint handling, and patients are often left dissatisfied. The complex, bureaucratic nature of complaints systems is often cited as an obstacle to meaningful investigation and learning, but a detailed examination of how such bureaucratic rules, regulations, and infrastructure shape complaint handling, and where change is most needed, remains relatively unexplored. We sought to examine how national policies structure local practices of complaint handling, how they are understood by those responsible for enacting them, and if there are any discrepancies between policies-as-intended and their reality in local practice. DESIGN: Case study involving staff interviews and documentary analysis. SETTING: A large acute and multi-site NHS Trust in England. PARTICIPANTS: Clinical, managerial, complaints, and patient advocacy staff involved in complaint handling at the participating NHS Trust (n=20). MAIN OUTCOME MEASURES: Not applicable. RESULTS: Findings illustrate four areas of practice where national policies and regulations can have adverse consequences within local practices, and partly function to undermine an improvement-focused approach to complaints. These include muddled routes for raising formal complaints, investigative procedures structured to scrutinize the 'validity' of complaints, futile data collection systems, and adverse incentives and workarounds resulting from bureaucratic performance targets. CONCLUSION: This study demonstrates how national policies and regulations for complaint handling can impede, rather than promote, quality improvement in local settings. Accordingly, we propose a number of necessary reforms, including patient involvement in complaints investigations, the establishment of independent investigation bodies, and more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints.

Field studies on the biological control of nematode parasites of sheep in the tropics, using the microfungus Duddingtonia flagrans.

Long-term field studies were conducted on two government managed small ruminant research farms, located in different geo-climatic regions and approximately 300 km separate from each other, on Peninsula Malaysia. The Infoternak trial (48 weeks) and the Chalok trial (43 weeks) each compared nematode parasite control in separately managed groups of young sheep, either short-term rotationally grazed around a suite of 10 paddocks in addition to receiving a daily supplement of Duddingtonia flagrans spores (Fungus Group); or similar groups of sheep being rotationally grazed alone (Control Group). The prevailing weather conditions at Infoternak farm were of below average rainfall conditions for the most of the trial. As a consequence, only very low worm infections (almost exclusively Haemonchus contortus) were acquired by the 17 sets of tracer lambs that grazed sequentially with the experimental lambs. However on all except 2 occasions in the early part of the trial, the mean tracer worm burdens were significantly lower (P < 0.05) and the experimental lambs grew significantly better (P = 0.054) in the Fungus Group. Rainfall at Chalok farm during the course of the trial was also below average. As a consequence infectivity of pastures was assumed to be relatively low based on faecal egg counts (epg) of the experimental sheep, which following an anthelmintic treatment prior to allocation, remained very low in both treatment groups. Faecal egg counts of undosed replacement lambs in the latter half of the Chalok study, showed a progressive increase in the Control Group to levels exceeding 3000 epg, whereas the Fungus Group remained static at approximately 500 epg. These results show that the deployment of the nematophagous fungus, D. flagrans, can improve the level of parasite control of sheep in the tropics above that which can be achieved by the short-term rotational grazing strategy alone.

Biological control of nematode parasites of small ruminants in Malaysia using the nematophagous fungus Duddingtonia flagrans.

Control of nematode parasites of small ruminants in a wet, tropical environment using the nematophagous fungus, Duddingtonia flagrans, was assessed in this study. Two methods of fungal delivery were tested, namely as a daily feed supplement, or incorporated into feed blocks. Initially, pen trials were conducted with individually penned groups of sheep and goats at dose rates of 125,000 spores and 250,000 spores/kg live weight per day. At the lower dose rate this reduction was between 80 and 90% compared with the pre-treatment levels. At the higher dose rate, there was virtually complete suppression (>99% reduction) of larval recovery. Trials using the fungal feed blocks, showed that when animals were individually penned, they consumed only small amounts of the block (particularly goats), hence little effect on larval recovery in faecal cultures was observed. Grouping animals according to species and dose rate induced satisfactory block consumption and subsequent high levels of larval reduction in faecal cultures. These larval reductions were mirrored by the presence of fungus in faecal cultures. This work was followed by a small paddock trial, whereby three groups of sheep were fed either a feed supplement without fungal spores, supplement with spores, or offered fungal blocks. The dose rate of spores in the latter two groups was 500,000 spores/kg live weight per day. Egg counts were significantly reduced in the two fungal groups, compared with the control group and the latter required two salvage anthelmintic treatments to prevent mortality due to haemonchosis. Pasture larval numbers on the two fungal group plots were also much lower than on the control plot.

KRAS mutations are not predictive for progression of preneoplastic gastric lesions.

Individuals with atrophic gastritis (n = 863) were recruited to participate in a chemoprevention trial in Nariño, Columbia. The volunteers were randomly assigned to intervention therapies, which included antibiotic treatment for Helicobacter pylori infection, and then daily dietary supplementation with antioxidant micronutrients in a 2(3) factorial design. Biopsies were obtained according to a specified protocol from designated areas in the stomach for each individual at baseline (before intervention therapy), at year 3, and at year 6. A systematic sample of 160 participants was selected from each of the eight treatment combinations, and the first exon of KRAS was examined for mutations. At year 3, the data indicated that individuals with KRAS mutations in their baseline premalignant stomach biopsies were 3.74 times as likely to progress to a higher premalignant stage than those who lacked baseline mutations (P = 0.04; C. Gong et al., Cancer Epidemiol. Biomark. Prevy. 8:167-171, 1999). However, after 6 years, baseline KRAS mutations failed to predict histological progression. Also, KRAS mutation in 72-month biopsies did not predict histological progression.

Recombinant oncotoxin AR209 (anti-P185erbB-2) diminishes human prostate carcinoma xenografts.

PURPOSE: Prostate cancer is the most common malignancy of males in the United States. Although the overall survival rate for early stage prostate cancer is good, if cancer recurs following curative therapies there is no adequate salvage therapy. Systemic chemotherapy has never been associated with any meaningful improvement in overall survival or overall objective benefit. There is a need to develop novel therapies for prostate cancer. MATERIALS AND METHODS: Two prostatic cancer cell lines, DU-145 and PC-3, were grown as subcutaneous xenografts in athymic nude mice. The recombinant oncotoxin AR209, formerly OLX-209 [e23(Fv)PE38KDEL]), has the specificity of an anti-p185erbB-2 antibody contained within a single-chain antibody domain (e23Fv) coupled to a portion of the Pseudomonas exotoxin A (PE38KDEL). Using Western blot analysis, the cell lines were shown to express p185erbB-2. The mice received either 3 i.v. injections, one every 2 days, of the recombinant oncotoxin AR209 or PBS, or were implanted with osmotic pumps that delivered a constant s.c. amount of AR209 or PBS. RESULTS: The oncotoxin was effective in reducing the size of s.c. prostatic xenografts in athymic nude mice. The data demonstrated that small tumors (<200 mm.3) were effectively reduced in size. However, larger tumors (>500 mm.3) were not effectively diminished. CONCLUSIONS: This study provides preliminary evidence for the utility of a recombinant oncotoxin in the treatment of prostate carcinoma. Recombinant oncotoxins may be an effective clinical addition for the management of metastatic prostate lesions in patients treated with conventional therapy.

Prognostic value of specific KRAS mutations in lung adenocarcinomas.

Adenocarcinomas of the lung remain a significant public health problem. Locally defined (stage I) tumors are considered amenable to resection with curative intent. However, only about 45% of these patients survive for 5 years. The median survival for more advanced tumors is drastically lower. Much research has been focused on identifying a valid genetic biomarker of prognosis. Mutations of the proto-oncogene KRAS have been identified by some groups as being a valid prognostic indicator for adenocarcinoma of the lung. To evaluate the effect of KRAS gene mutation on the survival of patients with lung adenocarcinoma, 181 archival tumors were examined by PCR and denaturing gradient gel electrophoresis. Mutations in either codon 12 or 13 were found in 31.5% of the samples. The most common mutation was a G-->T transversion in codon 12, representing 66.7% of the mutations. No difference was observed in the survival of patients with a KRAS mutation versus those whose tumors contained wild-type KRAS. This lack of difference was also observed when the analysis was restricted to those with stage I tumors or when patients with stage I or II disease were grouped together. However, certain amino acid substitutions, including cysteine, arginine, and aspartate, indicated a significantly poorer prognosis, whereas hydrophobic amino acid substitutions showed a significantly better prognosis than wild-type (P = 0.04). Sample sizes were small for this analysis due to the number of possible mutations. As expected, the stage of tumor at resection was the most significant predictor of outcome. Based on this study of 181 patients from two major medical centers located in different cities, we conclude that KRAS mutation status is not a satisfactory predictor of prognosis in lung adenocarcinoma, but the substitution of a polar or charged amino acid for the wild-type glycine residue may be a negative prognostic indicator.

Tumor specific Epstein-Barr virus infection is not associated with leiomyosarcoma in human immunodeficiency virus negative individuals.

BACKGROUND: Recent studies have suggested that the Epstein-Barr virus (EBV) is associated with leiomyosarcoma in children with human immunodeficiency virus (HIV) and in organ transplant recipients. To determine whether EBV is associated with leiomyosarcoma in HIV negative patients, the authors examined resected leiomyosarcomas for EBV and HIV. METHODS: Twenty-four leiomyosarcomas were studied and their diagnosis confirmed on pathologic review. From these specimens DNA was isolated. Tumor samples were analyzed for EBV and HIV using a polymerase chain reaction (PCR) technique followed by gel electrophoresis and Southern blot analysis. DNA from an EBV-infected human Burkitt's lymphoma cell line and peripheral blood from an HIV positive patient were used as positive controls for the presence of EBV and HIV, respectively. Immunohistochemistry was performed using an antibody to Epstein-Barr nuclear antigen. RESULTS: HIV was not present in any of the patients analyzed. EBV DNA was detected in tumor tissue; however, 80 cycles of PCR were used before EBV sequences were detected. Therefore, the data indicate that tumor tissue was not infected with EBV. The positive results observed after 80 cycles of PCR were likely due to infiltrating lymphocytes. Immunohistochemistry confirmed the lack of active or latent EBV infection in tumor cells. CONCLUSIONS: The results indicate that EBV is not associated with sporadic leiomyosarcoma in HIV negative patients. Therefore, the biology of leiomyosarcoma associated with HIV may be substantially different from the more common sporadic form.

Detection of K-ras mutations in resected primary leiomyosarcoma.

Mutation of the K-ras oncogene occurs frequently in human malignancy. However, there are few reports concerning K-ras mutations in soft-tissue sarcoma, including leiomyosarcoma. We therefore designed a study to determine the prevalence of mutations in the first exon of K-ras in leiomyosarcoma and to evaluate its prognostic potential. Fifty-one leiomyosarcomas were reviewed, and their diagnoses were confirmed on pathological review. Tissue blocks were retrieved, and new sections were prepared for confirmation of diagnosis. Additional tissue sections were used for DNA isolation. PCR and denaturing gradient gel electrophoresis (DGGE) were used to detect K-ras mutations in the first exon of genomic DNA isolated from the specimens. Seven (14%) K-ras mutations were detected using DGGE. Subsequent sequencing of the K-ras gene from each of the mutated tumors confirmed the DGGE results in each case. The median survival for patients whose tumors did not contain mutations of K-ras was 42 months (n = 42) versus 25 months (n = 7) for those with mutations (P = 0.06). However, patients with stages I and II tumors had a median survival of 82 months (n = 28) compared to 28 months for those with stages III and IV disease (n = 20, P = 0.02). The results suggest that K-ras codon 12 mutations are uncommon in leiomyosarcoma; however, when such mutations are found, there is a trend toward worse survival. Furthermore, the data confirm that stage is a significant prognostic indicator.