The 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 significantly 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 justified, 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.

Relations between anxiety sensitivity and panic symptoms in nonreferred children and adolescents.

Anxiety sensitivity (AS), the fear of anxiety-related sensations, has been posited to be a cognitive risk factor for the development of anxiety disorders but has been understudied in youth. The purpose of the present investigations was to evaluate relations between AS and panic symptoms in nonreferred children and adolescents. In Study 1, (N = 113, mean age, 13.98). scores on the Childhood Anxiety Sensitivity Index (CASI) predicted the experience of uncued panic attacks after controlling for general anxiety and depression, although the total variance accounted for was small. In Study 2 (N = 52; mean age, 9.48), the Panic/ Agoraphobia subscale of the Spence Children's Anxiety Scale was used as the criterion variable. CASI score again predicted panic symptoms after controlling for trait anxiety and depression. Identification of a risk factor for panic attacks and panic disorder in youth will have important implications for etiologic theory, intervention, and prevention.

Familial Kaposi's sarcoma and Paget's disease of bone.

Familial Kaposi's sarcoma and familial Paget's disease of bone have not previously been reported to occur in the one patient or the one family. We report on an 82-year-old female of Lebanese descent who was recently diagnosed with Kaposi's sarcoma and Paget's disease. Of the patient's eight siblings, seven had Paget's disease and two of these also had Kaposi's sarcoma. Histocompatibility leucocyte antigen (HLA) class I and II typing of the patient showed: A2, A3; B35, Bx; Bw6; Cw4; DR beta 1*1101 (an HLA-DR5 subtype), DR beta 3 and DQ beta 1*0301. Previous reports have described possible associations of familial Kaposi's sarcoma with HLA-DR5 and Paget's disease with DR2. DR beta 1*1104, DP beta 1*04 and DQw1. Genetic factors and possible viral aetiologies for each condition are reviewed.

Subungual squamous cell carcinoma presenting with minimal nail changes: a factor in delayed diagnosis?

Squamous cell carcinoma of the nail bed is a relatively uncommon tumour that may be diagnosed only after considerable delay. The first case presented is a 79-year-old man with a history of discomfort and discoloration affecting the right thumbnail of 3 years duration. The second case is a 70-year-old man who presented with a recurrent, offensive discharge from beneath the left thumbnail of 40 years duration. Clinical examination of the affected digits revealed minor nail abnormalities. The presence of tumour was fully apparent only after removal of the nail plate and inspection and biopsy of the nail bed. The cases demonstrate that subungual squamous cell carcinoma may present with prolonged symptoms and a deceptively benign appearance. The importance of consideration of the possibility of malignancy, removal of the nail plate for inspection of the nail bed and appropriate biopsy is emphasized.

A comprehensive study of genic variation in natural populations of Drosophila melanogaster. IV. Mitochondrial DNA variation and the role of history vs. selection in the genetic structure of geographic populations.

Preliminary studies with restriction fragment length polymorphisms of mitochondrial DNA (mtDNA) in natural populations of Drosophila melanogaster revealed considerable variation in terms of nucleotide sequence and overall size. In this report we present data from more isofemale lines and more restriction enzymes, and explore the utility of the data in inferring a colonization history of this species. Size variation in the noncoding A + T-rich region is particularly plentiful, with size variants occurring in all restriction site haplotypes in all populations. We report here classes of small-scale mobility polymorphisms (apparent range of 20 bp) in specific restriction fragments in the coding region. The variation in one such fragment appears to be generated even more rapidly than in the noncoding region. On the basis of the distribution of restriction site haplotypes, the species range can be divided into three major regions along longitudinal lines: Euro-African populations are the most diverse and are taken to be oldest; Far East populations have a complex distribution of haplotypes; Western Hemisphere populations are the least diverse and are interpreted to be the youngest. The history inferred from mtDNA alone is remarkably similar to one based on several nuclear markers. The mtDNA haplotype distribution is also very different from that of allozymes in these same populations. We interpret this as further evidence that natural selection is still the most parsimonious explanation for the parallel latitudinal allozyme clines in this species.

Mitochondrial DNA variation and genetic structure in populations of Drosophila melanogaster.

The understanding of the genetic structure of a species can be improved by considering together data from different types of genetic markers. In the past, a number of worldwide populations of Drosophila melanogaster have been extensively studied for several such markers, including allozymes, chromosomal inversions, and quantitative characters. Here we present results from a study of restriction-fragment-length polymorphisms of mitochondrial DNA (mtDNA) in 92 isofemale lines from many of the same geographic populations of D. melanogaster. Eleven restriction enzymes were used, of which four revealed restriction-site polymorphism. A total of 24 different haplotypes were observed, of which 18 were unique to single populations. In many populations, the unique haplotypes have reached high frequency without being observed in neighboring populations. A Wagner parsimony tree reveals that mutationally close variants show geographical clumping, suggesting local differentiation of mtDNA in populations. The Old-World and the New-World populations are differentiated, with the predominant Old-World haplotype being virtually absent from the New World. These results contrast with those for the nuclear genes, in which many loci show parallel clines in different continents, and suggest a common origin of D. melanogaster populations in North America.

A high pull torquing auxiliary for use with the Begg appliance.

Treatment of the severe Class II division 2 malocclusion is difficult whatever appliance system is used. A small auxiliary, for use with the Begg appliance, is described. This enables torque and intrusive forces to be delivered to the upper central incisors, using High Pull Headgear. A case treated using this device is shown, and the changes brought about are demonstrated.

Extensive variation and heteroplasmy in size of mitochondrial DNA among geographic populations of Drosophila melanogaster.

Size variation and heteroplasmy in mitochondrial DNA (mtDNA) are relatively common in natural populations of Drosophila melanogaster. Of 92 isofemale lines of flies obtained from various geographic regions throughout the world, 75 lines were homoplasmic and showed a total of 12 different mtDNA size classes. The remaining 17 lines were heteroplasmic, each line carrying two different mtDNAs, and, in all but one case, the mtDNAs in these heteroplasmic lines differed in size; a total of nine size classes was represented among them. In cases where one type was predominant within an individual, it was usually the smaller mtDNA. This finding parallels what was observed in homoplasmic lines, in that the smaller mtDNAs were much more common than the larger variants in most populations. The data suggest a high rate of mutational occurrence of mtDNA size variants and some natural selection against them.

A long-term follow-up of four cases treated with the Andresen appliance.

Four patients treated with Andresen appliances were recalled 20 years after treatment. While the results were quite acceptable to the patients, rather more change had occurred than might have been expected, especially in relation to continued growth after one would have expected it to have ceased, and in relation to the degree of the occlusal changes accompanying this growth. They demonstrate that a result thought to be stable even four years after treatment can change markedly well into adulthood.

Mitochondrial DNA variation in Drosophila pseudoobscura and related species in Pacific northwest populations.

We have analysed mitochondrial DNA (mtDNA) from Pacific Northwest populations of Drosophila pseudoobscura, D. persimilis, and D. miranda using six restriction enzymes. We find that HpaII restriction sites are hypervariable compared to the other enzymes used. This hypervariability allows construction of a maximum parsimony map linking each mtDNA genotype. Small insertions, possibly tandem duplications, appear to have arisen concomitantly with, or subsequent to, speciation events, perhaps within the A + T rich region. Convergence of mtDNA genotypes is also evident. Unlike findings for other populations of these species, we find little evidence of mitochondrial introgression between D. pseudoobscura and D. persimilis, despite their ability to produce fertile hybrid females.