Systemic nocardiosis due to Nocardia farcinica has not been reported in canine outbreaks. Two 14-week-old female Dogue de Bordeaux siblings presented with fever and severe, acute onset limb lameness; traumatic lesions with evidence of infection were identified over the lame limbs of both dogs. The patients were euthanised owing to lack of therapeutic response and rapid escalation to systemic infection with central nervous system manifestations. The post-mortem changes consisted of multiple disseminated abscesses, mainly affecting the skin and subcutis at the limb traumatic injuries, local and hilar lymph nodes, lung, kidney and brain. Bacterial culture and identification via MALDI-TOF and 16S rRNA sequencing revealed Nocardia farcinica from several of these sites in both dogs. Clinical significance of the isolate was supported by cytology of the post-mortem organs’ impression smears showing numerous branching filamentous bacteria associated with inflammation. The organism displayed marked multidrug-resistance. No history of immunosuppression was available, and immunohistochemistry ruled out viral pathogens as canine distemper and parvovirus. N. farcinica should be considered as a potential differential cause of sudden lameness and systemic infection in dogs with traumatic skin lesions over the limbs. This is the first reported small-scale outbreak of systemic nocardiosis in dogs due to N. farcinica.
Ray Moynihan
ABC Books, $A19.95, pp 308
ISBN 0 7333 0652 7
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Rating: ★★★
This is a meticulous and thoughtful critique of the amount of investigation and treatment experienced by patients in modern medicine. Take, for example, the worldwide explosion of diagnostic endoscopy for indigestion. Firstly, there is no evidence that it has resulted in a major improvement in health outcome. Secondly, an army of endoscopists has been created, who see this as all or most of their life’s work. Thirdly, armouries of ingenious but expensive endoscopes have been manufactured by a major new industry. Lastly, physicians have, as endoscopists, joined the league of big surgical earners for the first time (except for invasive cardiologists, who arrived there some time ago). So even if there were, as there may be, good reasons for restraint, what chance is there of achieving it? Might a careful history together with the minimum of investigation (a red cell count, for example) and the simplest of treatment be the first and, in many young adults, the safest and most cost effective approach?
Moynihan is young and a journalist, but he is not an angry young man, not even a latter-day Illich. He is talented: you will enjoy his clear and critical examination of complicated issues, and the trustees of the Harkness Foundation have this year awarded him a scholarship to Harvard. He has already won prizes for both medical and science journalism.
He is concerned at the inability of doctors to stand back from the treadmill of professional practice to examine and re-examine what we do and why. He sees us as driven by technological and pharmacological advance, by uncritical press and public opinion (regarding therapeutic and diagnostic fashion), and more than a little driven by financial interests—our own and those of industry. His purpose is to encourage public scrutiny and healthy scepticism of doctors, to weigh the risks, benefits, and fundamental uncertainties of medical practice, and to consider what is sensible, safe, and necessary.
We may have heard most of this before, but the issues have probably never been put more clearly, coherently, and sympathetically. The public has not yet taken these issues to heart, but the medical profession is starting to take seriously damage from “friendly fire.” That we still have a long way to go is neither surprising nor necessarily a criticism, but it makes a spur to greater effort welcome.
Protein metabolism in uraemia is reviewed. Very few, if any, disorders of amino acid metabolism can at present confidently be attributed to uraemia per se rather than to protein/energy deprivation. Retained urea nitrogen is recycled to the liver as ammonia; a proportion is reutilized for synthesis of non-essential amino acids and, if their carbon skeletons are supplied, for synthesis of essential amino acids. Practical applications of the reutilization of non-amino nitrogen in advanced chronic renal failure are being explored. Nevertheless, uraemic individuals readily become undernourished, and they should receive as much protein as their symptoms will permit.
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A prospective study of the process of application, selection, and admission to medical school was performed. St Mary's Hospital Medical School received 1478 UCCA applications for admission in October 1981: 94 (6.4%) applicants entered St Mary's in October 1981, 436 (29.5%) entered other medical schools, 176 (11.9%) read a subject other than medicine, and 772 (52.2%) did not enter university. The study included 12.6% of all applicants and 12.9% of all entrants to British medical schools in October 1981. Educational qualifications, demographic variables, type of schooling, family background, and the manner of application were examined in relation to overall selection. A level achievement was the major determinant of acceptance. O level achievement, early application, and medical parents had significant but smaller independent effects on the chance of acceptance. Social class, age, sex, and school type did not predict acceptance when corrected for academic and other factors. Few differences in personality, career preference, cultural interests or attitudes were found between those accepted and those rejected.
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