Pythium insidiosum is an oomycete, a fungal like microorganism, which infects mammals, causing pythiosis in animals and humans, especially in tropical and subtropical regions around the world. The treatment for this infection is very difficult, and therapeutic options commonly comprise surgery, immunotherapy and antimicrobial drugs. The present report describes the clinical healing of a dog with gastrointestinal pythiosis by treatment with a combination of antifungals and immunotherapy, as well as reviews the cases reported in the literature that used some type of therapy for canine pythiosis. A 2.5-year-old male beagle initially showed sporadic vomiting episodes, and this symptom became more frequent 5 months after the onset of clinical signs. Celiotomy procedure found thickness of the stomach wall extending to the pylorus and duodenum. A biopsy was performed, and the diagnosis of pythiosis was made by mycological, histopathological analyses and molecular identification. Therapy was based on an association of terbinafine plus itraconazole during 12 months and immunotherapy for 2.5 months. The healing of the dog reported here allows us to propose the use of immunotherapy associated with antifungal therapy to treat canine gastrointestinal pythiosis. However, additional studies should be performed on a larger number of patients to establish a standard treatment protocol for canine pythiosis.

The oomycete Pythium insidiosum is the pathogenic cause of pythiosis, a life-threatening disease that affects several animal species. Canines are the second most affected species, and the disease is characterized by the development of cutaneous and gastrointestinal lesions. While concomitant cutaneous and gastrointestinal lesions are rarely found in the same animal, this report documents a case of concurrent cutaneous and gastrointestinal pythiosis in an 18-month-old female Labrador. This dog had an ulcerative cutaneous lesion on the right thoracic region for 12 months that was unresponsive to itraconazole and terbinafine therapy. Two months prior to death and concurrent with the cutaneous lesion, the dog became anorexic with frequent vomiting and bloody stools. At necropsy, a cutaneous lesion that extended subcutaneously into the intercostal muscles was observed. Additionally, the large intestine contained two lesions that caused luminal narrowing. Organs were collected, routinely processed and stained using hematoxylin and eosin and Gomori methenamine silver. Histological examination of the lesions in the large intestine and on the skin revealed areas of necrosis surrounded by a pyogranulomatous infiltrate. Occasionally, black, septate, branching hyphae were detected following staining with Gomori methenamine silver. The diagnosis of pythiosis was confirmed using immunohistochemical methods. This report describes the occurrence of concomitant gastrointestinal and cutaneous lesions in a dog and highlights the therapeutic difficulties encountered with this disease.

Patients and prescribers have recently been affected by interruptions to the supply of all formulations of the H2 antagonist ranitidine as a result of possible contamination with N‐nitrosodimethylamine. Here, Marco Motta and Mike Wilcock present the outcomes of their study evaluating the implications of these shortages for patients taking ranitidine from six GP practices in Cornwall.

Introduction Sepsis poses a challenge for general practice, and sepsis awareness raising amongst healthcare professionals is a priority, with general practices expected to have an identified sepsis lead who has updated staff.1 The Royal College of General Practitioners (RCGP) made sepsis a clinical priority to raise awareness of how appropriate GP action could have an impact.2 In September 2020, locality-based prescribing meetings were held focusing on sepsis. For the 2021/22 General Practice Prescribing Quality Scheme it was decided to ascertain what practices had in place to manage suspected sepsis. Aim To assess whether GP practices in Cornwall have the structure and processes in place to manage sepsis. Methods A pre-piloted paper survey, based on a literature review, was delivered to all practices. There were seven questions (mixture of closed questions and questions allowing expanded answers, and a free text comment option). The sepsis lead GP responded on behalf of the practice. Survey completion, along with completion of other elements of the Prescribing Quality Scheme, generated an incentive payment to practices. This service evaluation did not require ethical approval. Results Fifty-one of 57 (89%) surgeries responded. When asked if all practice staff were familiar with the terminology “Red Flag Sepsis’, 36 replied yes, 4 replied only clinical staff, and 11 no. Receptionist training on this topic had occurred in 33 practices, but not in 18. All 51 replied they had the necessary equipment readily available to assess patients with possible sepsis. As regards intravenous antibiotics routinely stocked in the practice, five had none, and for those that kept antibiotics it was a mixture of benzylpenicillin, ceftriaxone, cefotaxime or Tazocin. Thirty-seven were unable to take a blood culture prior to first dose of antibiotics for a patient with Red Flag Sepsis, including one highlighting such a patient would have immediate hospital referral. Fourteen answered yes to this question, including one also highlighting immediate hospital referral. Thirty-five practices had a safety-net resource aligning with NICE guidance3 for giving to adults, parents and carers being managed in the community, whilst ten said no and 5 clarified that they give verbal advice but no written information. Fifteen had implemented change in their practice that they would share with other practices though only 12 provided brief details. Free text comments generated themes around staff training, including administration of IV antibiotics by GPs, and whether practices should be taking blood cultures and associated practical issues. Discussion/Conclusion The RCGP states that ideally all staff in a sepsis aware practice will have had education about sepsis.2 We found this had not occurred in 18/51 (35%) practices, and in 11/51 (22%) practices staff appeared unfamiliar with the terminology “Red Flag Sepsis’. The issue of taking blood cultures (73% said they were unable to do this) generated concerns and further discussion with Microbiology colleagues is needed. Practices have identified actions to be taken subsequent to this survey. We recognise limitations of a small survey from late 2021 conducted in a single centre in England, possibly subject to social-desirability bias. References 1. NHS England. CCG Improvement and Assessment Framework 2017/18: Technical Annex NHS England: Central Analytical team. Available from: https://www.england.nhs.uk/wp-content/uploads/2017/11/ccg-technical-annex-2017-18-v1-1.pdf 2. Royal College of General Practitioners. Sepsis toolkit [Internet]. Available from: https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/sepsis-toolkit.aspx 3. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. (NICE guideline 51). 2016. Available from: https://www.nice.org.uk/guidance/ng51

Lymphoma is one of the most prevalent forms of cancers in dogs, however, it is uncommon on the skin. Cutaneous lymphoma can present as erythematous and exfoliative superficial lesions or raised masses. Histologically, cutaneous lymphomas are subdivided into epitheliotropic and non-epitheliotropic. Epitheliotropic lymphomas is mostly seen as mycosis fungoides and more rarely as pagetoid reticulosis or Sézary syndrome. Non-epitheliotropic lymphomas include anaplastic large T-cell lymphoma, unspecified peripheral T-cell lymphoma, lymphomatoid granulomatosis, intravascular lymphoma, and subcutaneous panniculitis-like T-cell lymphoma. This literature review presents macroscopic and histopathological aspects of canine cutaneous lymphomas.

Reducing inappropriate antibiotic prescribing in primary care is a key element of antimicrobial stewardship. This study carried out in GP surgeries in Cornwall examined whether clarithromycin was being prescribed in accordance with NICE guidance, and whether allergy status and symptoms were correctly recorded in the case of patients who had penicillin allergy noted.

Optimising antibiotic prescribing in the primary care setting is a key component of the UK antimicrobial resistance (AMR) strategy. In this project, the authors worked with eight GP practices in Cornwall that had high levels of antibiotic prescribing to help them find ways to improve their prescribing and reduce antibiotic consumption, using defined daily doses (DDDs) as a measure of consumption.

Recognition and early treatment of sepsis are important to optimise patient outcomes, but this is an area that many general practices currently find challenging. Here, the authors discuss the findings of their short survey of GP practices in Cornwall to determine current approaches to the management of suspected sepsis in primary care and to identify areas for improvement.