• Describes an audit undertaken in the East of England on antibiotic prescribing in general dental practice.• The protocols of an original North West of England audit published in 2001 were deliberately replicated, in order to be able to pool the data and obtain a sample size of at least 1% of all UK dentists.• The combined Regional results confi rm that clinical audit reduces both the number of errors made by dental practitioners when writing out a prescription, as well as the number of those which are issued inappropriately, as compared to contemporary prescribing guidelines. I N B R I E FThe impact of clinical audit on antibiotic prescribing in general dental practice Objective To reduce the number of antibiotics inappropriately prescribed by general dental practitioners, and to increase overall prescription accuracy. Design A prospective clinical audit carried out between September and March of 2002-3 and 2003-4. Setting General dental practices in Eastern England. Subjects and methods The pre-audit antibiotic prescribing practices of 212 general dental practitioners were recorded over an initial six week period. On each occasion this included which antibiotic had been chosen, together with its dose, frequency and duration, as well as the clinical condition and reason for which the prescription had been raised. When related to prophylaxis, the patient's medical history was also noted. Following education on contemporary prescribing guidelines, presentations which illustrated the practitioners' previous errors, and the agreement of standards to be achieved, the process was repeated for another six weeks, and the results compared. Results In the pre-audit period, 2,951 antibiotic prescriptions were issued, and during the audit this was reduced by 43.6% to 1,665. The majority were for therapeutic reasons, with only 10.5% and 13.6% for medical prophylaxis during the pre-audit and audit periods respectively. Over both periods, amoxicillin and metronidazole were the two most commonly prescribed antimicrobials (63.4% and 21.2% respectively). In the pre-audit period, only 43% of all prescriptions were error free in dose, frequency, and/or duration of use, but this rose signifi cantly to 78% during the audit. Equally, using contemporary published guidelines, out of all the prescriptions made in the pre-audit period, only 29.2% were deemed to be justifi ed, as compared to 48.5% during the audit. Conclusions Clinical audit, in conjunction with education, and prescribing guidelines can favourably change antibiotic prescribing patterns among general dental practitioners.

suMMARY Frequent abnormalities of left ventricular function were detected in 212 established diabetic patients using non-invasive techniques.Diabetics without angina or heart failure (n= 185) were significantly different from normal subjects (n=50) in beat-to-beat variation, ratio ofpre-ejection period to left ventricular ejection time, pre-ejection period index, isovolumic relaxation time, and interval from minimal dimension to mitral valve opening.Diabetics with angina (n=18) were similar to control subjects with angina (n=-25); they showed a significant dimension change during the isovolumic period as compared with other diabetics and normals. Sixteen diabetics without angina also showed outward motion during the isovolumic period (incoordinate relaxation) and 13 had abnormal systolic time intervals. Four diabetics suffered a myocardial infarction during the study period; all had previously shown incoordination.Comparison of diabetics with a diastolic blood pressure below 100 mmHg and between 100 and 125 mmHg showed that the latter had a thicker posterior wall; the enlarged systolic dimension and reduced fractional shortening were the result of the inclusion of five of the 11 diabetic subjects with heart failure in the hypertensive group. Insulin-dependent diabetics tend to have more pronounced abnormalities of left ventricular function than those not requiring insulin.Patients selected from a diabetic clinic frequently have impaired left ventricular function, and ventricular hypertrophy, when present, in primarily caused by hypertension.There is increasing evidence that diabetics have abnormalities of left ventricular function in the absence of clinical heart disease.'-6 Whether this results from small vessel disease of the myocardium, the metabolic effects of diabetes, or coronary artery disease is unknown, but the Framingham study' showed that diabetics suffered an incidence of heart failure in excess of that predicted from atherogenic risk factors.A wide range of abnormalities in systolic and diastolic left ventricular function has been shown in diabetics but the number of patients in each group tends to be small and usually only one clinical type is included. For example, patients without microvascular disease have been shown to have normal6 and abnormal' systolic time intervals, and those with

The results of this study are in keeping with available, largely urban-based literature, with respect to predictive factors of home death. Further prospective study, with an emphasis on choice regarding place of care and GP involvement with palliative care patients, is warranted.

The use of intracephalic reference lines in cephalometric assessment is valid only if these lines bear some constant relationship to the true horizontal and to each other. Otherwise, the use of a true horizontal would give the benefit that cephalometric assessment would be based on the same standards as clinical judgment. In using a true horizontal, however, the radiograph must be taken with the head in a reproducible natural posture. A study was carried out to assess the reproducibility of a natural head posture using a simple positioning method in a standard cephalostat, and to assess the variation in the relationship of the sella-nasion, Frankfort, maxillary and mandibular reference lines, to a true horizontal and to each other. Though in their mean inclinations the Frankfort and the maxillary reference lines were almost parallel to each other and to the true horizontal, the range of variation for all the reference lines was considerable. The range of variation in the reference lines was greater than the error of reproduction of head position, and the range of variation of the slope of the mandibular line was no greater than that for the slope of each of the other three lines. The sella-nasion line was reproduced more accurately that the other reference lines, using a digitizer. The possibilities of a simple cephalometric analysis based on a true horizontal are outlined.