Medical training for police officers in specialist role (D13): A retrospective review of patient report forms from 2010–2015

Introduction

D13 is a nationally agreed bespoke medical training package for specialist firearms police officers introduced in 2010. Patient report forms are completed after every episode of care provision.

Methods

A review of patient report forms submitted by police firearms officers in five regions of England over the five years since the introduction of D13.

Results

Officers attended a large range of incidents, both traumatic and medical, minor and life critical. The majority (69.5%) were responded to as part of a normal police response, while 30.5% of cases were due to primary firearm deployments. Catastrophic haemorrhage was dealt with in 8.1% of cases including the use of haemostatic dressings and tourniquet application. Airway interventions were required in 36.1% of patients and 50.4% required interventions for external bleeding.

Discussion

From a background of a minimum of 18 h for Standard and 24 h for Enhanced courses and with regular simulation refreshers, specialist police officers, who are part of a robust clinical governance process, play an important role in providing immediate medical care in non-permissive or dangerous environments where ambulance personnel will not be present and when the officers are frequently first on scene.

Bacteria Associated With Piezodorus guildinii (Hemiptera: Pentatomidae), With Special Reference to Those Transmitted by Feeding

The redbanded stink bug, Piezodorus guildinii (Westwood) (Hemiptera: Heteroptera: Pentatomidae), is a rapidly growing pest damaging southern US agriculture. Pentatomid stink bugs are known to vector bacterial, fungal, and viral plant diseases. However, bacteria associated with redbanded stink bugs and their vector potential have not yet been assessed. In this study, we 1) cultured and identified bacteria transmitted by feeding of redbanded stink bug and 2) described bacteria from guts of redbanded stink bug individuals using next-generation sequencing of 16S rRNA genes. Nineteen bacteria transmitted by feeding of redbanded stink bug on soybean agar were isolated and identified via Sanger sequencing of near full length 16S RNA genes. The transmitted bacteria belonged to at least a dozen species in eight genera and included potential plant pathogens (Phaseolibacter flectens), plant beneficials (Bacillus atropheus), and possible insect beneficials (Acinetobacter sp. and Citrobacter farmeri). A total of 284,448 reads were captured from Illumina MiSeq sequencing of the uncultured gut bacteria community. Fifty-one putative bacteria species (74% of the estimated total species richness) were identified via matches to NCBI databases. The bacteria metagenome contained potential plant and insect pathogens (Erwinia persicina, E. rhaponici, Brenneria nigrifluens, Ralstonia picketti, and Serratia marcescens) and beneficials (Pantoea dispersa, Klebsiella oxytoca, Clostridium butyricum, and Citrobacter farmeri).

A multicentre phase II pilot study of epirubicin and Taxol (paclitaxel) in patients with advanced breast cancer

Anthracyclines are the gold standard monotherapy for metastatic breast cancer. Higher response rates are seen with drug combinations, especially with newer agents such as taxanes. The purpose of this study was to evaluate the toxicity and activity of the combination of paclitaxel and epirubicin in patients with advanced breast cancer. Thirty-five women with locally advanced or metastatic breast cancer (first and second relapse) were treated with epirubicin 75 mg/m2 and paclitaxel 200 mg/m2 3-weekly. Six centres recruited 35 patients; 34 (97%) were assessable for response. Eighteen had undergone prior chemotherapy, including six (17%) with anthracycline-containing regimens. Grade 4 neutropenia was found in 33 patients (94%), which was of 4 days' average duration; however, infective complications were rare, with only nine cycles (6%) complicated by neutropenic sepsis. There were two sepsis-related deaths. Symptomatic cardiotoxicity was infrequent, although a >15% decline in cardiac function was recorded in five patients (14%). Grade 3 peripheral neuropathy occurred in three patients (9%). The overall response rate was 50% (95% confidence interval 33-67) (complete response 12%; partial response 38%), with a median duration of response of 31 weeks. The median time to progression was 27 weeks, with a median survival of 48 weeks. This regimen appears to be a relatively safe, tolerable and effective treatment for advanced breast cancer. A United Kingdom Co-ordinating Committee for Cancer Research Phase III trial (AB-01) comparing this combination of epirubicin and paclitaxel with cyclophosphamide and paclitaxel completed accrual in November 1999.

Differences in the carboxy-terminal (Putative phospholipid binding) domains of Clostridium perfringens and Clostridium bifermentans phospholipases C influence the hemolytic and lethal properties of these enzymes

The phospholipases C of C. perfringens (alpha-toxin) and C. bifermentans (Cbp) show >50% amino acid homology but differ in their hemolytic and toxic properties. We report here the purification and characterisation of alpha-toxin and Cbp. The phospholipase C activity of alpha-toxin and Cbp was similar when tested with phosphatidylcholine in egg yolk or in liposomes. However, the hemolytic activity of alpha-toxin was more than 100-fold that of Cbp. To investigate whether differences in the carboxy-terminal domains of these proteins were responsible for differences in the hemolytic and toxic properties, a hybrid protein (NbiCalpha) was constructed comprising the N domain of Cbp and the C domain of alpha-toxin. The hemolytic activity of NbiCalpha was 10-fold that of Cbp, and the hybrid enzyme was toxic. These results confirm that the C-terminal domain of these proteins confers different properties on the enzymatically active N-terminal domain of these proteins.

A novel sorbent for the determination of clenbuterol in bovine liver

The use of three C18 sorbents in matrix solid phase dispersion (MSPD) for the determination of clenbuterol in bovine liver fortified at 5 ng g-1 is described. MSPD grade C18 sorbents give rise to more efficient blending and packing of the material for subsequent washing and analyte elution in comparison with a non-MSPD grade C18 sorbent. Following enzymatic deconjugation of the liver extracts, radioimmunoassay is used as the method of determination. The mean recovery of clenbuterol with all sorbents is comparable and within the range 86-96% in two intra-assay studies (n = 3). The liver extracts in each case are highly coloured. The variation in recovery is observed to be lowest with MSPD grade C18 (end-capped). This sorbent was used in further studies to evaluate the use of solid phase extraction (SPE), post MSPD, with normal phase aminopropyl or mixed mode cation exchange columns for extract purification. The mean recovery of clenbuterol (n = 4, inter-assay study) following MSPD and normal phase SPE clean-up was 95 +/- 15% and 89 +/- 9% at fortification levels of 1 and 2.5 ng g-1, respectively.

Crystallization and preliminary X-ray diffraction studies of alpha-toxin from two different strains (NCTC8237 and CER89L43) of Clostridium perfringens

The alpha-toxin of Clostridium perfringens is the major virulence determinant for gas gangrene in man. The gene encoding the alpha-toxin has been cloned into E. coli from two strains of the bacterium (NCTC8237 and CER89L43) and subsequently purified to homogeneity. The two strains of alpha-toxin differ by five amino acids, resulting in the toxin from NCTC8237 being sensitive to chymotrypsin digestion while that from CER89L43 is resistant. The alpha-toxin from each of these strains has been crystallized in two different forms by the hanging-drop vapour-diffusion method at 293 K. CER89L43 form I crystals belong to space group R32 and have two molecules in the crystallographic asymmetric unit and a unit cell with a = b = 151.4, c = 195.5 A, alpha = beta = 90, gamma = 120 degrees. The crystals diffracted to dmin = 1.90 A. The characteristics of the NCTC8237 form I crystals have already been reported. The form II crystals from both strains belong to space group C2221 with one molecule in the crystallographic asymmetric unit and, for strain CER89L43, have cell dimensions a = 61.05, b = 177.50, c = 79.05 A, alpha = beta = gamma = 90 degrees, while for strain NCTC8237 the cell dimensions are a = 60.50, b = 175.70, c = 80.20 A, alpha = beta = gamma = 90 degrees. The crystals diffracted to maximum resolutions of 1.85 and 2.1 A for the CER89L43 and the NCTC8237 strains, respectively.

Structure of the key toxin in gas gangrene

Clostridium perfringens alpha-toxin is the key virulence determinant in gas gangrene and has also been implicated in the pathogenesis of sudden death syndrome in young animals. The toxin is a 370-residue, zinc metalloenzyme that has phospholipase C activity, and can bind to membranes in the presence of calcium. The crystal structure of the enzyme reveals a two-domain protein. The N-terminal domain shows an anticipated structural similarity to Bacillus cereus phosphatidylcholine-specific phospholipase C (PC-PLC). The C-terminal domain shows a strong structural analogy to eukaryotic calcium-binding C2 domains. We believe this is the first example of such a domain in prokaryotes. This type of domain has been found to act as a phospholipid and/or calcium-binding domain in intracellular second messenger proteins and, interestingly, these pathways are perturbed in cells treated with alpha-toxin. Finally, a possible mechanism for alpha-toxin attack on membrane-packed phospholipid is described, which rationalizes its toxicity when compared to other, non-haemolytic, but homologous phospholipases C.

Molecular variation between the alpha-toxins from the type strain (NCTC 8237) and clinical isolates of Clostridium perfringens associated with disease in man and animals

The alpha-toxin produced by the type strain of Clostridium perfringens (NCTC 8237) was shown to differ from the alpha-toxins produced by most strains of C. perfringens isolated from man and from calves with respect to reactivity with a neutralizing monoclonal antibody (DY2F5D11). The difference in antibody binding correlated with three differences in the deduced amino acid sequence (Ala174 to Asp174; Thr177 to Ala177; Ser335 to Pro335) of the alpha-toxins. Using octapeptides synthesized on the basis of the amino acid sequences from these regions of variability, it was shown that the Ala174 to Asp174 change had the greatest effect on reducing the binding of monoclonal antibody DY2F5D11 to the alpha-toxin. These differences did not affect the enzymic or toxic properties of the protein. However, the phospholipase C activity of the alpha-toxin produced by strain NCTC 8237 was more susceptible to inactivation by chymotrypsin. The changes in amino acid sequence did not affect the ability of a C-terminal domain vaccine, derived from the alpha-toxin of strain NCTC 8237, to induce protection against the alpha-toxin from a bovine enteric strain of C. perfringens.

Psychosexual dysfunction in women with gynaecological cancer following radical pelvic surgery

OBJECTIVE

To assess the prevalence and severity of psychosexual dysfunction in women treated for cancer of the cervix and vulva by radical vulvectomy, Wertheim's hysterectomy and pelvic exenteration; and to identify the risk factors for sexual morbidity and ways in which it might be reduced.

DESIGN

Retrospective study of patients by questionnaire and semistructured interview, 6 months to 5 years following surgery.

SETTING

Gynaecology-Oncology Unit of a general hospital.

PATIENTS

105 English speaking women with gynaecological cancer.

RESULTS

90% of the women in relationships had been sexually active prior to surgery. Of this group, 24% had no sexual difficulties post-operatively; 66% of the latter still had problems more than 6 months later, and 15% of the latter never resumed intercourse (excluding those with a colpectomy). 82% of those aged less than 50 years who had had radiotherapy suffered sexual dysfunction. Lack of desire was the commonest problem, and half the women felt that their sexual relationship had deteriorated, yet only 16% felt that their marriage had worsened. Younger women were more likely to attribute personal and marital distress to their sexual problems. More information on sexual matters would have been liked by 28% of the women.

CONCLUSIONS

Sexual dysfunction is common following radical pelvic surgery and tends to remain a chronic problem. As well as organic causes there is a strong psychogenic element brought about by loss of fertility, disfigurement, depression and anxiety about one's desirability as a sexual partner. The presence of a stable relationship before the diagnosis of cancer helps women cope better, and young single women are a very vulnerable group. Patients want more information on sexual matters and the provision of sexual counselling may improve outcome in the future.

Psychosocial adjustment following major gynaecological surgery for carcinoma of the cervix and vulva

One-hundred and five women had undergone major gynaecological surgery for carcinoma of the cervix and vulva were interviewed retrospectively to elicit post-operative psychosocial and psychosexual problems. This interview took place between 6 months and 5 yr after surgery. Responses to the Hospital Anxiety and Depression Scale indicated that 20% of the women were 'probable' cases of anxiety and 21% were 'definite' cases. On the depression scale, 18% were 'doubtful' cases and 14% were 'definite' cases. Scores on the scales were not associated with age of the woman, the type of operation or the time period between being interviewed and the operation. Two-thirds of the women who were sexually active prior to the operation indicated ongoing sexual problems when interviewed and the presence of these problems was found to be significantly associated with the woman's level of anxiety.

The care of patients undergoing surgery for gynaecological cancer: the need for information, emotional support and counselling

This study was undertaken by interviewing 105 patients who had undergone major gynaecological surgery for carcinoma of the cervix or vulva in the previous 5 years. A high proportion of the women was still found to be depressed and anxious when interviewed and the majority reported chronic sexual problems. The women were asked if they had received enough information regarding their illness and its treatment, and a high proportion would have liked to have had more information on the after-effects of the operation, including physical, sexual and emotional aspects. Many of the younger women would have liked their partner to have been included in the discussions and 25% of the 40 partners who responded to the questionnaire would have liked more information on the illness and its treatment. The women also indicated their needs for emotional support, discussion and counselling.