Readmissions after appointments with nurse prescribers: A register-based study.

BACKGROUND: Increasing number of nurse prescribers could be part of a solution to the shortage of physicians, improve access to treatment and curb the rise in healthcare costs; however, readmissions after nurse prescribers' appointments are under-researched. AIMS: To describe and compare clients' initial appointments with nurse prescribers and physicians. In addition, client readmissions within 60 days in the target organisation after nurse prescribers' and physicians' appointments were investigated. DESIGN: Retrospective register-based follow-up study. METHODS: Data included client appointments (n = 3986) with nurse prescribers and physicians, and clients' readmissions (n = 9038) from 1 January 2018 to 31 December 2019 from one hospital district in Finland. Data were analysed statistically using frequencies, percentages, rate ratios and cross-tabulation. STROBE checklist was used. RESULTS: Initial appointments including trimethoprim, pivmecillinam, phenoxymethyl penicillin, chloramphenicol, fusidic acid and cephalexin prescriptions with nurse prescribers (n = 36) were 2131, and physicians (n = 140) 1855. On average, client readmissions (within 60 days) per initial appointment were 2.10 after appointments with nurse prescribers and 2.46 after physicians. After initial appointments, including phenoxymethyl penicillin prescriptions, with nurse prescribers, clients had more readmissions in all age groups than after initial appointments with physicians. However, in all, after initial appointments with physicians, clients had a higher proportion of readmissions. CONCLUSION: Clients have fewer readmissions after appointments with nurse prescribers than physicians, including the same prescriptions. Nurse prescribers' skills may not have been fully utilised. Physicians treated many patients whose diseases nurse prescribers might have been able to treat based on the nurse prescribers' rights. However, physician clients may have more demanding service requirements.

Antibiotic prescribing trends in primary care 2014-2022.

Antimicrobial resistance (AMR) is a global healthcare challenge that governments and health systems are tackling primarily through antimicrobial stewardship (AMS). This should, improve antibiotic use, avoid inappropriate prescribing, reduce prescription numbers, aligning with national/international AMS targets. In primary care in the United Kingdom (UK) antibiotics are mainly prescribed for patients with urinary and respiratory symptoms (22.7% and 46% of all antibiotic prescriptions respectively). This study aimed to capture the time-series trends (2014-2022) for commonly prescribed antibiotics for respiratory and urinary tract infections in primary care in England. Trends for Amoxicillin, Amoxicillin sodium, Trimethoprim, Clarithromycin, Erythromycin, Erythromycin ethylsuccinate, Erythromycin stearate, Doxycycline hyclate, Doxycycline monohydrate and Phenoxymethylpenicillin (Penicillin V) were determined. In doing so providing evidence regarding meeting UK antibiotic prescribing rate objectives (a 15% reduction in human antibiotic use 2019-2024). Time series trend analysis of 62,949,272 antibiotic prescriptions from 6,370 General Practices in England extracted from the National Health Service (NHS) Business Services Authority web portal were explored. With additional investigation of prescribing rate trends by quintiles of the Index of Multiple Deprivation (IMD). Overall, there is a downwards trend in antibiotic prescribing for those explored. There is an association between IMD, geographical location, and higher antibiotic prescribing levels (prescribing hot spots). England has a well-documented North-South divide of health inequalities, this is reflected in antibiotic prescribing. The corona virus pandemic (COVID-19) impacted on AMS, with a rise in doxycycline and trimethoprim prescriptions notable in higher IMD areas. Since then, prescribing appears to have returned to pre-pandemic levels in all IMDs and continued to decline. AMS efforts are being adhered to in primary care in England. This study provides further evidence of the link between locality and poorer health outcomes (reflected in higher antibiotic prescribing). Further work is required to address antibiotic use in hot spot areas.

The Penicillin for the Emergency Department Outpatient treatment of CELLulitis (PEDOCELL) trial: update to the study protocol and detailed statistical analysis plan (SAP).

BACKGROUND: Cellulitis is a painful, potentially serious, infectious process of the dermal and subdermal tissues and represents a significant disease burden. The statistical analysis plan (SAP) for the Penicillin for the Emergency Department Outpatient treatment of CELLulitis (PEDOCELL) trial is described here. The PEDOCELL trial is a multicentre, randomised, parallel-arm, double-blinded, non-inferiority clinical trial comparing the efficacy of flucloxacillin (monotherapy) with combination flucloxacillin/phenoxymethylpenicillin (dual therapy) for the outpatient treatment of cellulitis in the emergency department (ED) setting. To prevent outcome reporting bias, selective reporting and data-driven results, the a priori-defined, detailed SAP is presented here. METHODS/DESIGN: Patients will be randomised to either orally administered flucloxacillin 500 mg four times daily and placebo or orally administered 500 mg of flucloxacillin four times daily and phenoxymethylpenicillin 500 mg four times daily. The trial consists of a 7-day intervention period and a 2-week follow-up period. Study measurements will be taken at four specific time points: at patient enrolment, day 2-3 after enrolment and commencing treatment (early clinical response (ECR) visit), day 8-10 after enrolment (end-of-treatment (EOT) visit) and day 14-21 after enrolment (test-of-cure (TOC) visit). The primary outcome measure is investigator-determined clinical response measured at the TOC visit. The secondary outcomes are as follows: lesion size at ECR, clinical treatment failure at each follow-up visit, adherence and persistence of trial patients with orally administered antibiotic therapy at EOT, health-related quality of life (HRQoL) and pharmacoeconomic assessments. The plan for the presentation and comparison of baseline characteristics and outcomes is described in this paper. DISCUSSION: This trial aims to establish the non-inferiority of orally administered flucloxacillin monotherapy with orally administered flucloxacillin/phenoxymethylpenicillin dual therapy for the ED-directed outpatient treatment of cellulitis. In doing so, this trial will bridge a knowledge gap in this understudied and common condition and will be relevant to clinicians across several different disciplines. The SAP for the PEDOCELL trial was developed a priori in order to minimise analysis bias. TRIAL REGISTRATION: EU Clinical Trials Register (EudraCT number: 2016-001528-69). Registered on 5 April 2016. ClinicalTrials.gov, ID: NCT02922686 . Registered on 9 August 2016.

Voltammetric determination of penicillin V in pharmaceutical formulations and human urine using a boron-doped diamond electrode.

Simple, sensitive and selective differential pulse voltammetric method for determination of penicillin V on a bare (unmodified) boron-doped diamond electrode has been developed. Penicillin V provided highly reproducible and well-defined irreversible oxidation peak at very positive potential of +1.6V (vs. Ag/AgCl). The optimum experimental conditions for oxidation of penicillin V were achieved in acetate buffer solution (pH 4.0). The modulation amplitude of 0.1V, modulation time of 0.05s and scan rate of 0.05Vs(-1) were selected as optimum instrumental parameters for differential pulse voltammetry. Linear response of peak current on the concentration in the range from 0.5 to 40µM with coefficient of determination of 0.999, good repeatability (RSD of 1.5%) and detection limit of 0.25µM were observed without any chemical modifications and electrochemical surface pretreatment. The effect of possible interferents such as stearic acid, glucose, urea, uric acid and ascorbic acid appeared to be negligible which evidently proved the good selectivity of method. The practical analytical utility of proposed method was demonstrated by determination of penicillin V in pharmaceutical formulations (tablets) and human urine samples with satisfactory recoveries (from 98 to 101% for tablets and 97 to 103% for human urine).

Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network's PATCH II trial.

BACKGROUND: Cellulitis (erysipelas) of the leg is a common, painful infection of the skin and underlying tissue. Repeat episodes are frequent, cause significant morbidity and result in high health service costs. OBJECTIVES: To assess whether prophylactic antibiotics prescribed after an episode of cellulitis of the leg can prevent further episodes. METHODS: Double-blind, randomized controlled trial including patients recently treated for an episode of leg cellulitis. Recruitment took place in 20 hospitals. Randomization was by computer-generated code, and treatments allocated by post from a central pharmacy. Participants were enrolled for a maximum of 3 years and received their randomized treatment for the first 6 months of this period. RESULTS: Participants (n=123) were randomized (31% of target due to slow recruitment). The majority (79%) had suffered one episode of cellulitis on entry into the study. The primary outcome of time to recurrence of cellulitis included all randomized participants and was blinded to treatment allocation. The hazard ratio (HR) showed that treatment with penicillin reduced the risk of recurrence by 47% [HR 0·53, 95% confidence interval (CI) 0·26-1·07, P=0·08]. In the penicillin V group 12/60 (20%) had a repeat episode compared with 21/63 (33%) in the placebo group. This equates to a number needed to treat (NNT) of eight participants in order to prevent one repeat episode of cellulitis [95% CI NNT(harm) 48 to ∞ to NNT(benefit) 3]. We found no difference between the two groups in the number of participants with oedema, ulceration or related adverse events. CONCLUSIONS: Although this trial was limited by slow recruitment, and the result failed to achieve statistical significance, it provides the best evidence available to date for the prevention of recurrence of this debilitating condition.

Studying a disease with no home--lessons in trial recruitment from the PATCH II study.

BACKGROUND: Cellulitis is a very common condition that often recurs. The PATCH II study was designed to explore the possibility of preventing future episodes of cellulitis, with resultant cost savings for the NHS. This was the first trial to be undertaken by the UK Dermatology Clinical Trials Network. As such, it was the first to test a recruitment model that involved many busy clinicians each contributing just a few patients. METHODS: A double-blind randomised controlled trial comparing prophylactic antibiotics (penicillin V) with placebo tablets, for the prevention of repeat episodes of cellulitis of the leg. Primary outcome was time to subsequent recurrence of cellulitis. RESULTS: The PATCH II study was closed to recruitment having enrolled 123 participants from a target of 400. Whilst the recruitment period was extended by 12 months, it was not possible to continue beyond this point without additional funds. Many factors contributed to poor recruitment: (i) changes in hospital policy and the introduction of community-based intravenous teams resulted in fewer cellulitis patients being admitted to hospital; ii) those who were admitted were seen by many different specialties, making it difficult for a network of dermatology clinicians to identify suitable participants; and iii) funding for research staff was limited to a trial manager and a trial administrator at the co-ordinating centre. With no dedicated research nurses at the recruiting centres, it was extremely difficult to maintain momentum and interest in the study. Attempts to boost recruitment by providing some financial support for principal investigators to employ local research staff was of limited success. DISCUSSION: The model of a network of busy NHS clinicians all recruiting a few patients into large clinical studies requires further testing. It did not work very well for PATCH II, but this was probably because patients were not routinely seen by dermatologists, and recruitment took place prior to research support being available through the Comprehensive Clinical Research Network (CCRN). There is a balance to be struck between asking a lot of centres to recruit just a few patients, and asking a few centres to recruit a lot of patients. Giving modest funds to principal investigators to buy local research nurse time did not work well, probably because too little research time was bought, and it was difficult to separate research tasks from the nurses existing clinical duties. National research infrastructure networks such as the Comprehensive Clinical Research Network will overcome many of the problems encountered in the PATCH II trial. TRIAL REGISTRATION: The trial registration number is ISRCTN03813200.

Quantitative determination of penicillin V and amoxicillin in feed samples by pressurised liquid extraction and liquid chromatography with ultraviolet detection.

A rapid and simple method is proposed for the routine determination of amoxicillin (AMOX) and penicillin V (PENV) in swine feedingstuffs. The method is based on pressurised liquid extraction (PLE) followed by high performance liquid chromatography with ultraviolet detection (PLE-HPLC-UV) for antibiotic analysis. Parameters affecting PLE procedure, such as temperature, solvent composition, number of extraction cycles and sample cell size, were evaluated in order to achieve the highest extraction efficiency. The optimised method employed 11mL extraction cells, acetonitrile-water mixtures (25:75, v/v) for AMOX and (50:50, v/v) for PENV, as extraction solvent, 102.07atm of extraction pressure, 50 degrees C of extraction temperature, 5min of static time and 60% flush volume of the cell size. Extracts were filtered and directly analysed by HPLC-DAD/UV without further clean-up. Mean recovery rates for feed samples fortified with 200-500mgkg(-1) of both antibiotics were 86% for AMOX (RSD< or =6%) and 95% for PENV (RSD< or =3%). The method was successfully applied to the analysis of a commercial medicated swine feedingstuff, and the results were in good agreement with those obtained using mechanical shaking or ultrasonic extraction combined with solid phase extraction (UE-SPE), previously applied in the literature for feed analysis. The extraction efficiencies were evaluated by statistical comparison (analysis of variance, ANOVA-single factor) of the results obtained using the different extraction methods. Compared to the alternative techniques, PLE offers several practical advantages: easy to perform, fast, savings in solvent volume and in time, all steps are fully automated and further clean-up is not necessary for penicillin analysis.

Reduction of antibiotics sales and sustained low incidence of bacterial resistance: Report on a broad approach during 10 years to implement evidence-based indications for antibiotic prescribing in Jönköping County, Sweden.

BACKGROUND: Increased prevalence of resistance in major pathogens decreases the possibility to treat common infectious conditions. In the beginning of the 1990s, resistant pneumococci spread among children in southern Sweden, which alarmed both the profession and the medical authorities. We describe the measures taken to curb the spread of resistance and to reduce the use of antibiotics in outpatient care. METHOD: A national organization, Strama (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance), was initiated in 1994 and a regional committee was formed in Jönköping County in 1995. A multifaceted program was started aiming at reducing antibiotic use in the county by 25% and that the prevalence of resistant pneumococci should not increase. RESULTS: The efforts by the Jönköping County committee has resulted in a 31% total reduction of the consumption of antibiotic drugs in primary care between 1993 and 2005 and a 50% reduction among children aged 0 to 4 years. There has been no increase in the prevalence of resistant pneumococci or Haemophilus influenzae in the county. The decrease in antibiotic use was greater than the average in Sweden. CONCLUSION: Our regional efforts have been successful. This has probably been achieved by a sustained strategy including repeated campaigns in the media, information to the profession, implementation of guidelines, and feedback to the profession on data on antibiotic prescribing and resistance. We believe it is of outmost importance not only to inform the profession but also the public on the limited effects of antibiotics in most respiratory tract infections.

Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings.

BACKGROUND: How to use clinical score, the rapid streptococcal antigen test (RSAT), and culture results is uncertain for efficient management of acute pharyngitis in adults. METHODS: This prospective cohort study included 372 adult patients with pharyngitis treated at a Swiss university-based primary care clinic. In eligible patients with 2 to 4 clinical symptoms and signs (temperature >or=38 degrees C, tonsillar exudate, tender cervical adenopathy, and no cough or rhinitis), we performed an RSAT and obtained a throat culture. We measured sensitivity and specificity of RSAT with culture as a gold standard and compared appropriate antibiotic use with cost per patient appropriately treated for the following 5 strategies: symptomatic treatment, systematic RSAT, selective RSAT, empirical antibiotic treatment, and systematic culture. RESULTS: RSAT had high sensitivity (91%) and specificity (95%) for the diagnosis of streptococcal pharyngitis. Systematic throat culture resulted in the highest antibiotic use, in 38% of patients with streptococcal pharyngitis. Systematic RSAT led to nearly optimal treatment (94%) and antibiotic prescription (37%), with minimal antibiotic overuse (3%) and underuse (3%). Empirical antibiotic treatment in patients with 3 or 4 clinical symptoms or signs resulted in a lower rate of appropriate therapy (59%) but higher rates of antibiotic use (60%), overuse (32%), and underuse (9%). Systematic RSAT was more cost-effective than strategies based on empirical treatment or culture: 15.00 dollars, 26.00 dollars, and 32.00 dollars, respectively, per patient appropriately treated. CONCLUSIONS: The RSAT we used is a valid test for diagnosis of pharyngitis in adults. A clinical approach combining this RSAT and clinical findings efficiently reduces inappropriate antibiotic prescription in adult patients with acute pharyngitis. Empirical therapy in patients with 3 or 4 clinical symptoms or signs results in antibiotic overuse.

Off-label prescribing to children: attitudes and experience of general practitioners.

AIM: To identify experience with and attitudes towards paediatric off-label prescribing in primary care. METHOD: A prospective questionnaire survey was sent to a sample of Scottish primary care practices (346 doctors in 80 general practices located throughout Scotland). RESULTS: Two hundred and two (58%) completed questionnaires were returned. Over 70% of GPs admitted to being familiar with the concept, and 40% to knowingly prescribing off-label. The most important sources of paediatric prescribing information were the British National Formulary (81%), personal experience (71%) and previous prescription notes (45%). The most common reason given by GPs for off-label prescribing was prescribing for a younger age than recommended, although prescribing data confirm that age is the least important and dose the most important reason for such prescribing. When asked to comment upon different causes for off-label prescribing, 80% of respondents expressed appropriate awareness of and concern for the described scenarios. Over 97% of GPs ranked development of paediatric formulations and clearer dosage information more highly than clinical trials as a means to reducing off-label prescribing. CONCLUSIONS: Despite high levels of off-label prescribing in primary care in the UK, the majority of GPs claimed to be familiar with the concept, although less than half were aware of this common practice. A clear disparity between perceived and actual reasons for off-label prescribing was noted, possibly due to a reliance on personal experience, colleague experience or previous patient prescription notes as a guide to prescribing.

Uncertainty analysis of penicillin V production using Monte Carlo simulation.

Uncertainty and variability affect economic and environmental performance in the production of biotechnology and pharmaceutical products. However, commercial process simulation software typically provides analysis that assumes deterministic rather than stochastic process parameters and thus is not capable of dealing with the complexities created by variance that arise in the decision-making process. Using the production of penicillin V as a case study, this article shows how uncertainty can be quantified and evaluated. The first step is construction of a process model, as well as analysis of its cost structure and environmental impact. The second step is identification of uncertain variables and determination of their probability distributions based on available process and literature data. Finally, Monte Carlo simulations are run to see how these uncertainties propagate through the model and affect key economic and environmental outcomes. Thus, the overall variation of these objective functions are quantified, the technical, supply chain, and market parameters that contribute most to the existing variance are identified and the differences between economic and ecological evaluation are analyzed. In our case study analysis, we show that final penicillin and biomass concentrations in the fermenter have the highest contribution to variance for both unit production cost and environmental impact. The penicillin selling price dominates return on investment variance as well as the variance for other revenue-dependent parameters.

Lack of penicillin resensitization in patients with a history of penicillin allergy after receiving repeated penicillin courses.

BACKGROUND: Up to 10% of the population reports an allergy to penicillin, yet more than 80% of these individuals lack penicillin-specific IgE antibodies. A negative result on a penicillin skin test is highly accurate in identifying who can safely receive the antibiotic at the time of testing. However, its negative predictive value for future courses is unknown because it is uncertain whether patients with a history of penicillin allergy are at risk of becoming resensitized. OBJECTIVE: To determine the rate of penicillin resensitization in adult patients with a history of penicillin allergy after they are challenged with repeated courses of oral penicillin. METHODS: Adult patients with a history of penicillin allergy consistent with an IgE-mediated mechanism were recruited and underwent penicillin skin testing. Those with negative skin test results were challenged with 3 successive 10-day courses of penicillin V potassium (250 mg by mouth 3 times a day), providing their penicillin skin test results remained negative prior to each course. Patients with positive skin test results were not challenged. RESULTS: Of 53 patients with initially negative skin test results, 46 completed the protocol, and each tolerated all 3 courses of penicillin with negative skin test results throughout. No patients had a converted skin test result from negative to a positive, yielding a resensitization rate of 0% (upper 95% confidence interval, 2.1%). CONCLUSIONS: Adult patients with a history of penicillin allergy are not at increased risk of resensitization after receiving 3 courses of oral penicillin. Because a negative penicillin skin test result is predictive for subsequent oral administrations beyond the time of testing, adult patients with a history of penicillin allergy can be skin tested electively, which may avoid unnecessary treatment with alternate broad-spectrum antibiotics.

Manejo de la faringoamigdalitis estreptocóccica en pacientes adultos o adolescentes / Management of streptococcal pharyngitis in adult or adolescent patients

La faringitis estreptocóccica es una importante causa de morbilidad y frecuente fuente de mal uso de antimicrobianos. No más de 10 a 15 por ciento de los adultos que consultan por odinofagia aguda y fiebre tiene una faringitis causada por Streptococcus pyogenes. Una terapia innecesaria expone a los pacientes a reacciones alérgicas, otros eventos adversos e incrementos en los costos de salud. En países como Chile, donde la enfermedad reumática ha declinado considerablemente, la confirmación de S. pyogenes por tests rápido o cultivo faríngeo es la aproximación clínica más lógica. Los tests rápidos para diagnóstico etiológico tienen una buena sensibilidad (80 a 90 por ciento) y especificidad (95 a 99 por ciento). Estos tests pueden ser efectuados a un costo razonable y los resultados negativos pueden ser confirmados mediante cultivo. Diversas opciones terapéuticas están disponibles hoy en día para erradicar a S. pyogenes de la faringe, un marcador subsidiario de eficacia en la prevención de enfermedad reumática. Estas alternativas no mejoran significativamente la eficacia obtenida con penicilina V oral, tienen similar frecuencia de eventos adversos y se caracterizan por un significtivo incremento de costos. Por otra parte, los esquemas terapéuticos basados en amoxicilina oral o penicilina G benzatina intramuscular tienen similar costo que el tratamiento estándar. Tratamientos abreviados efectuados con diversos fármacos durante 5 ó 6 días, tienen eficacia similar que esquemas estándares pero no reducen el costo total de tratamiento

Optimization of 6-aminopenicillanic acid (6-APA) production by using a new immobilized penicillin acylase.

A new immobilized penicillin acylase (ECPVA) was obtained by covalent binding of penicillin acylase from Streptomyces lavendulae on Eupergit C. Enzymic hydrolysis of penicillin V catalysed by ECPVA was optimized using a 2(3) factorial design of experiments, and the selected parameters for this study were pH, temperature and substrate concentration. The immobilized enzyme showed an optimal pH value of 9.5-10.5, and an optimal temperature of 60 degrees C, whereas its soluble counterpart showed the same optimal pH value and a lower optimal temperature of 50 degrees C.

Major change in the use of antibiotics following a national programme: Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance (STRAMA).

In order to reduce inappropriate use of antibiotics and to counteract the increase in antimicrobial resistance in community-acquired and nosocomial infections, a national project was initiated in Sweden in 1994: the Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance. In the first years the project focused on inappropriate prescribing of antibiotics to children with respiratory tract infections and on the surveillance of resistance in pneumococci. Statistics on antibiotic sales on a national and county level and for different age-groups were studied. Between 1993 and 1997 antibiotic prescribing was reduced by 22%, from 16.3 to 13.0 defined daily doses (DDD) per 1000 inhabitants/d. The reduction was most pronounced for children, 0-6-y-old, from 15.7 to 9.7 DDD/1000 children/d. Macrolides and amoxicillin/co-amoxyclav decreased most. There were large variations in antibiotic sales in different counties, and a decrease was also noted in counties starting from a low level. In the county with the highest sales in 1993, antibiotic prescribing to children was reduced by 40%. The national frequency of penicillin-non-susceptible pneumococci (MIC > or =0.1 mg/l) has not increased during the 1990s and the increasing incidence in southern Sweden seems to have been curtailed. During the period that the project has been running, a major change in the use of antibiotics, especially for pre-school children, has been achieved.

Desarrollo Tecnológico de la Suspensión Oral de Fenoximetilpenicilina 125 mg / Technological development of a 125 mg oral phenoxymethylpenicillin suspension

Se describió el desarrollo tecnológico de una formulación de fenoximetilpenicilina suspensión oral 125 mg para uso pediátrico, utilizando la vía seca que se inicia con la mezcla del principio activo con los sabores, estabilizadores, edulcorantes y lubricantes hasta lograr un producto estable y con las características que lo hacen adecuado para el uso que se destina. Se estudió la estabilidad del producto terminado desde el punto de vista tecnológico y químico con resultados satisfactorios. El medicamento diseñado cumple con los requisitos más actuales para su comercialización y forma parte del surtido estable de producción de la Empresa Farmacéutica "8 de marzo"

An audit of antibiotic prescribing in third molar surgery.

The use of antibiotics as a prophylactic measure against infection is widespread following the removal of impacted third molars. The advantages of using such prophylaxis appear to be marginal and there is little substantial evidence to support the use of second and third generation antibiotics for routine prophylaxis. An audit of antibiotic prescribing practices in the University Dental Hospital National Health Service Trust (Cardiff) was undertaken and demonstrated the potential for saving large sums of money whilst apparently incurring no clinical disadvantage. The value of such audit process in oral and maxillofacial surgery is in identifying best practice followed by measuring and, where possible, improving standards.