Rapid diagnosis of Capnocytophaga canimorsus septic shock in an immunocompetent individual using real-time Nanopore sequencing: a case report.

BACKGROUND: Rapid diagnosis and appropriate treatment is imperative in bacterial sepsis due increasing risk of mortality with every hour without appropriate antibiotic therapy. Atypical infections with fastidious organisms may take more than 4 days to diagnose leading to calls for improved methods for rapidly diagnosing sepsis. Capnocytophaga canimorsus is a slow-growing, fastidious gram-negative bacillus which is a common commensal within the mouths of dogs, but rarely cause infections in humans. C. canimorsus sepsis risk factors include immunosuppression, alcoholism and elderly age. Here we report on the application of emerging nanopore sequencing methods to rapidly diagnose an atypical case of C. canimorsus septic shock. CASE PRESENTATION: A 62 year-old female patient was admitted to an intensive care unit with septic shock and multi-organ failure six days after a reported dog bite. Blood cultures were unable to detect a pathogen after 3 days despite observed intracellular bacilli on blood smears. Real-time nanopore sequencing was subsequently employed on whole blood to detect Capnocytophaga canimorsus in 19 h. The patient was not immunocompromised and did not have any other known risk factors. Whole-genome sequencing of clinical sample and of the offending dog's oral swabs showed near-identical C. canimorsus genomes. The patient responded to antibiotic treatment and was discharged from hospital 31 days after admission. CONCLUSIONS: Use of real-time nanopore sequencing reduced the time-to-diagnosis of Capnocytophaga canimorsus in this case from 6.25 days to 19 h. Capnocytophaga canimorsus should be considered in cases of suspected sepsis involving cat or dog contact, irrespective of the patient's known risk factors.

Referrals of patients to colorectal cancer genetics services in south-east Scotland.

The discovery that genetic factors are involved in the aetiology of colorectal cancer, has prompted many relatives of affected individuals to seek genetic counselling and screening. This paper describes the demand for genetic services by families with colorectal cancer in south-east Scotland, their expectations and views of the service offered. The annual referral rate over the 21-month study period, for patients with a family history of colorectal cancer, was 0.11 per 1000 patients on general practitioner lists. This is one third of the rate for patients with a family history of breast cancer and in comparison with the breast cancer group, relatives of colorectal cancer patients were significantly older and less socially deprived. Approximately one third were referred via a hospital specialist unit. One hundred patients were included in the study. Mean (+/- standard deviation) age was 43 (+/- 10.7 years), 75 were female and 31 were self referrals. Before the consultation, almost half the patients had an inflated perception of their risk and there was little change at follow-up. There was an improvement in objective understanding after counselling which was sustained up to 6 months but only two thirds remembered their objective risk accurately. Most patients were satisfied with the consultation. Our findings suggest the need to educate individuals, in particular men, younger people and the more socially deprived, about the relevance of a family history of colorectal cancer and to facilitate patients' comprehension of their risk status.

Informing the public health management of typhoid and paratyphoid: the Australian context.

OBJECTIVE: To examine outcomes of public health management of notified enteric fever cases in South-East Queensland over the past five years. METHODS: Notification records of typhoid and paratyphoid infection in South-East Queensland 2008-2012 (inclusive) were reviewed to determine likelihood of cases and contacts adhering to present or previous recommendations for faecal clearance/screening, duration of infectiousness of cases and extent of local transmission to contacts. RESULTS: Sixty-nine of 85 cases and 218 of 265 contacts submitted at least one faecal specimen. Cases were 2.7 (95%CI 1.2-6.0) and contacts were 4.4 (95%CI 3.0-6.4) times more likely to complete recommended faecal clearance/screening under previous compared to present guidelines (requiring more specimens). In ten cases with positive post-treatment specimens, last recorded infectiousness was 19 days to six months after notification. The documented rate of local transmission of infection was 18/1,000 contacts submitting at least one faecal specimen (95%CI 6-48/1,000). CONCLUSIONS: Local transmission risk of enteric fever in South-East Queensland is low, although small numbers of cases may have prolonged bacilli excretion post-treatment. More complex clearance/screening regimens are associated with decreased compliance. IMPLICATIONS: Pursuing extensive faecal clearance/screening regimens is unlikely to be effective in terms of public health management of enteric fever in South-East Queensland. We suggest a unified national approach focussing on cases/contacts at high risk of disease transmission.

The development of a psychoeducational intervention for women living with an increased risk of breast cancer.

Research has shown a widespread need for written information on topics related to familial risk of breast cancer amongst women who have been living with an increased risk of the disease for several years. This article describes the development of a psychoeducational intervention designed to meet the needs of these women. Following a review of the literature and existing information resources, a multidisciplinary group developed a written information pack consisting of scientific and psychosocial (self-help) information with the aim of improving knowledge and reducing cancer worry. The information pack has been evaluated by seven independent health professionals and piloted on eight women at increased risk of breast cancer. Aspects of readability and presentation have been considered. The results of a randomised controlled trial of the intervention, which will inform the current provision of clinical services for these women, will be reported elsewhere.

A pilot randomized controlled trial of an early multidisciplinary model to prevent disability following traumatic injury.

PURPOSE: Chronic pain, posttraumatic stress disorder (PTSD), and depression are common outcomes following traumatic injury. Yet, screening and early intervention to prevent the onset of these disorders do not occur routinely in acute trauma settings. This pilot study examined the clinical utility of screening and early multidisciplinary intervention for reducing disability following traumatic injury. METHOD: 142 non-severe head injured trauma inpatients (26% female, Injury Severity Score M = 9.65, M age = 36 years) were assessed for injury-related factors, pain, and psychological function within 4 weeks post injury. Patients were randomly allocated to a Multidisciplinary Intervention (MI) or Usual Care (UC) group. MI patients received assessment and treatment at one and 3 months post injury from pain and rehabilitation medicine doctors, physiotherapists, occupational therapists, and clinical psychologists. Outcomes at 6 months were then compared. RESULTS: Acute pain intensity, posttraumatic adjustment, depression and acute trauma symptoms, and alcohol use predicted a significant 26%, 49%, 56%, and 30% of the variance in pain, depressive, and PTSD severity, and physical mobility respectively at 6 months. Despite MI group patients reporting no improvement in the severity of pain and psychological symptoms, these patients reported significantly improved relief from pain symptoms as a result of treatment at 6 months. Twenty four per cent of the UC group initially below the cut-off for being at risk of developing PTSD/Depression received new clinical diagnoses at 6 months compared with none of the 'not at risk' MI group attendees who remained asymptomatic. CONCLUSIONS: Early findings point to the value of early screening to identify patients at risk of treatable pain, physical, and psychological impairments. Moreover, early multidisciplinary intervention models following traumatic injury show promise for protecting against the onset of posttraumatic psychological disorders.

Avoiding inappropriate invitations to cancer screening programmes: the role of primary care.

OBJECTIVES: To examine current procedures for cancer screening invitation list (SIL) checking in primary care, and to make recommendations for the future use of these procedures. SETTING: Cancer screening departments/units and associated general practices across England. METHODS: 1) An analysis of the outputs of screening programme SIL checking, and accompanying practice questionnaire, for cancers of the cervix (9 screening centres, 36 general practices), breast (6 centres, 76 practices) and bowel (pilot hub, 7 practices)--supplemented by an audit of calls to screening centres to identify inappropriate invitations; 2) a national postal questionnaire survey sent to all 80 breast screening departments across England and 320 associated general practices; 3) telephone interviews with 13 NHS screening staff to obtain detailed perspectives about SIL checking procedures. RESULTS: SIL checking in primary care is undertaken by a variety of clinical and non-clinical staff. It plays a useful role in cervical screening with tangible evidence of refinements to the SIL and support from both primary care and screening centre staff. Conversely, its role in breast and bowel screening is not supported by the results of this study. Overall, there is no significant evidence of adverse effects from inappropriate invitations. CONCLUSIONS: SIL checking in primary care for cervical cancer should continue, but its use in breast and bowel cancer screening is not supported by our results. New ways of undertaking the SIL checking process to make it more accurate and less burdensome should be examined.