The acquisition of clinical experience during GP training - how can we mitigate for the impact of COVID-19?

The COVID-19 pandemic has profoundly impacted the way general practice is run and this is expected to have had a knock-on effect upon GP training. A questionnaire-based study was designed to investigate what was happening to GP trainees 16 months into the pandemic in terms of opportunities to develop clinical experience and clinical decision-making. We also asked trainers and trainees for ideas on how we might mitigate for the effects of COVID-19. In particular, there has been decreased exposure to clinical examination during the pandemic and there appear to be gaps in opportunities to learn from urgent and unscheduled care settings and to develop skills in rapid clinical decision-making. It is interesting to consider what general practice will look like when the pandemic is over and how this will this affect the GP training curriculum going forwards. Although response rates were low, we were able to determine some emerging themes for national, local and educational review going forwards to help shape and improve GP training for the future.

Legislative and regulatory aspects of molluscan health management.

The world population is growing quickly and there is a need to make sustainable protein available through an integrated approach that includes marine aquaculture. Seafood is already a highly traded commodity but the production from capture fisheries is rarely sustainable, which makes mollusc culture more important. However, an important constraint to its continued expansion is the potential for trade movements to disseminate pathogens that can cause disease problems and loss of production. Therefore, this review considers legislative and regulatory aspects of molluscan health management that have historically attempted to control the spread of mollusc pathogens. It is argued that the legislation has been slow to react to emerging diseases and the appearance of exotic pathogens in new areas. In addition, illegal trade movements are taken into account and possible future developments related to improvements in areas such as data collection and diagnostic techniques, as well as epidemiology, traceability and risk analysis, are outlined.

Co-infection with Pseudomonas anguilliseptica and Delftia acidovorans in the European eel, Anguilla anguilla (L.): a case history of an illegally trafficked protected species.

Inspections by customs agents at Barcelona airport discovered 420 kg of contraband glass eels prepared for shipment to Hong Kong. After confiscation of these animals by police, they were transported to holding facilities to be maintained until after a judicial hearing. Upon arrival, they were separated into two groups and held under ambient flow-through conditions in fresh water. During their captivity period, several peaks in mortality occurred and multiple bacterial strains were isolated from moribund animals. Sequencing of 16S rDNA was used to determine specific identity of the isolates. An initial isolation of Pseudomonas anguilliseptica was treated with oxytetracycline. A subsequent isolation of Delftia acidovorans proved resistant to oxytetracycline and was treated with gentamicin in combination with sulphadiazine-trimethoprim. Once the health condition of the animals was stabilized, they were partitioned into groups and subsequently released as part of a restocking effort for the species following the guidelines of Regulation (EC) 1100/2007 (Anon 2007). This represents the first record for both bacterial species in the host Anguilla anguilla in the Spanish Mediterranean.

More than skin deep? Emerging therapies for chronic cutaneous GVHD.

The options for treating skin disease after haemopoietic progenitor cell transplant (HPCT) have broadened considerably over the last decade to include much more than topical steroids and emollients. This article reviews current and emerging therapies for chronic cutaneous GVHD, a well-recognised complication of HPCT. Alongside skin-directed therapies, there is now a wide range of systemic agents with differing targets for which an evidence base is emerging. Of particular interest, we summarise the role of electrocorporeal photopheresis, a therapy increasingly used in the United Kingdom to treat severe sclerodermoid manifestations of GVHD. We include a discussion of the expanding knowledge of the pathogenesis of cutaneous GVHD, which is informing our understanding and development of second line therapies (for example, the role of B cells and the utility of rituximab). Additionally, we draw attention to challenges encountered in the evaluation of chronic GVHD treatments and highlight recommendations for further research that may enable haematologists and dermatologists to provide better care for these patients. Finally, we present a clinical algorithm to aid the approach to treating limited and extensive disease and steroid refractory or persistent disease where steroid sparing may be necessary.

The spread of pathogens through trade in aquatic animals and their products.

It is well known that the transboundary spread of infectious diseases is aided by trade in live animals and the consequences can be severe if, as a result, a pathogen broadens its host range to new species. Trade in aquatic animal species is increasing, and aquaculture is also expanding to meet the growing human population's demands for animal protein. Moreover, it is clear that aquaculture has created potential new pathways by which pathogens and diseases may be introduced or spread to new areas. The risk of pathogen transfer is generally considered greater for the movement of live aquatic animals than for the movement of processed and dead products. The currently available health standards support the concept of minimising the risk of disease and pathogen incursion while, at the same time, avoiding unjustifiable or unnecessary impediments to trade. Nevertheless, the international spread of diseases through the movement of animals still occurs, despite these standards. Consequently, this paper considers the evidence linking international trade in aquatic animals and aquatic animal-derived products with the transmission and spread of diseases. The authors provide examples of pathogen transfer leading to disease spread and considerthe situation of emerging diseases, as well as the need for a holistic approach to deal with risk-based threats at their source.

Epizootic haematopoietic necrosis virus--an assessment of the likelihood of introduction and establishment in England and Wales.

Epizootic haematopoietic necrosis virus (EHNV) is an iridovirus that affects perch (Perca fluviatilis) and rainbow trout (Oncorhynchus mykiss). It emerged in Australia in the 1980s and has not been discovered elsewhere. It causes a high level of mortality in perch resulting in steep population declines. The main possible routes of introduction of the virus to England and Wales are the importation of infected live fish or carcasses. However, no trade in live susceptible species is permitted under current legislation, and no importation of carcasses currently takes place. The virus is hardy and low levels of challenge can infect perch. Therefore, mechanical transmission through the importation of non-susceptible fish species should be considered as a potential route of introduction and establishment. Carp (Cyprinus carpio) have been imported to the UK from Australia for release into still-water fisheries. A qualitative risk assessment concluded that the likelihood of EHNV introduction and establishment in England and Wales with the importation of a consignment of carp was very low. The level of uncertainty at a number of steps in the risk assessment scenario tree was high, notably the likelihood that carp become contaminated with the virus and whether effective contact (resulting in pathogen transmission) is made between the introduced carp and susceptible species in England and Wales. The virus would only establish when the water temperature is greater than 12 degrees C. Analysis of 10 years of data from two rivers in south-west England indicated that establishment could occur over a period of at least 14 weeks a year in southern England (when average water temperature exceed 12 degrees C). Imports of live fish from Australia need to be evaluated on a case-by-case basis to determine which, if any, sanitary measures are required to reduce the assessed risk to an acceptable level.

Diversity among strains causing bacterial kidney disease in salmonid fish.

A study was made of the biochemical, cultural, morphological, physiological and serological characters of 25 Gram-positive bacterial isolates of bacterial kidney disease in salmonid fish. Two distinct homogenous phena and seven single-member clusters were defined as a result of overall similarity based on analyses with the Jaccard coefficient. One phenon was equated withCorynebacterium pyogenes, but the second represents a novel taxon.