Audit Of Clinical Practice Research Articles

1389 Parenteral Nutrition in Very Low Birth Weight Newborns: Audit of Clinical Practice

Background and AimsParenteral nutrition (PN) is an integral part of neonatal intensive care, especially in the early nutritional support of very low birthweight (VLBW) newborns. However, it is associated with...

OC03.02: Pregnancies with a mean gestational sac diameter ≥ 20 mm and no visible embryo: a 12 year retrospective audit of clinical practice

To assess the performance of ultrasound criteria for the diagnosis of early pregnancy failure with an intrauterine gestational sac in the absence of a detectable embryo. This was a retrospective audit of the electronic records of patients seen in the early pregnancy unit of King's College Hospital, London from December 1998 to June 2011. The clinical protocol that was in place during that time period stated that a) only an experienced operator could make the diagnosis of a non-viable pregnancy in the absence of an embryo with a mean gestational sac diameter (MGSD) of > 20 mm b) all scans that made the diagnosis of early pregnancy failure had to be checked by a second examiner c) where this was not feasible or there was diagnostic uncertainty, the scan had to be repeated at an interval of at least one week. All ultrasound scans were performed transvaginally by Gynaecologists trained in early pregnancy ultrasonography. We identified all the pregnancies examined where the MGSD was ≥ 20 mm in the absence of a detectable embryo, and determined the outcome of the pregnancy in those women who returned for repeat assessment. There were 48,670 pregnancies recorded during the 12 year period. Of these, 936 (1.9%) cases met the audit criteria. 520 (55.6%) women had a repeat scan. 37/520 (7.1%) had an embryo with cardiac activity detected on follow up scan. These were all singleton pregnancies. Of the 37 ongoing pregnancies, 23 were live births at term, nine subsequently miscarried, two had terminations for social indications and three were lost to follow up. Overall, a minimum of 23/936 (2.5%) women with a MGSD > 20 mm had viable pregnancies resulting in a live birth. Five of these women had a MGSD > 25 mm. In our clinical practice, the diagnosis of early embryonic demise cannot be made with sufficient accuracy on a single ultrasound examination using either 20 mm or 25 mm as cut-off values for MGSD when no embryo is visible.

The Implications of Inheritance for Clinical Management

Since the advent of genotyping, recognition of heritable disease has been perceived as an opportunity for genetic diagnosis or new gene identification studies to advance understanding of pathogenesis. Until recently, however, clinical application of DNA-based testing was confined largely to Mendelian disorders. Even within this remit, predictive testing of relatives is cost-effective only in diseases in which the majority of families harbor mutations in known causal genes, such as adult polycystic kidney disease and hypertrophic cardiomyopathy, but not dilated cardiomyopathy. Confirmatory genetic testing of index cases with borderline clinical features may be economic in the still smaller subset of diseases with limited locus heterogeneity, such as Marfan syndrome. Furthermore, Mendelian diseases account for ≈5% of total disease burden.1 Genome-wide association studies have made headway in elucidating the genetic contribution to the more common, complex diseases, and high throughput techniques promise to facilitate integration of genetic analysis into clinical practice. Nevertheless, many genes remain to be identified and implementation of genomic profiling as a population screening tool would not be cost-effective at present. The implications of heredity, however, extend beyond serving as a platform for genetic analysis, influencing diagnosis, prognostication, and treatment of both index cases and relatives, and enabling rational targeting of genotyping resources. This review covers acquisition of a family history, evaluation of heritability and inheritance patterns, and the impact of inheritance on subsequent components of the clinical pathway. Eliciting a family history is the first step to determining whether a known diagnosis is heritable or symptoms of unknown etiology have a hereditary basis. Both narrative and diagrammatic approaches are integral to data collection, the former including questioning for diseases that recur within the family and the latter involving construction of a pedigree or family tree. Incorporation of psychosocial and interactional data, such as emotional relationships (harmony, apathy, …

Pregnancy outcome in women with gestational diabetes: results of a four‐year audit

AbstractThe objective of this audit was to compare pregnancy outcome in women with gestational diabetes mellitus (GDM) managed with diet/lifestyle advice, versus those requiring additional insulin therapy.We undertook a retrospective audit of clinical practice comprising 416 consecutive women with GDM and live singleton pregnancies who delivered over a four‐year period. Pregnancy outcome measures were compared for women on diet/lifestyle advice only versus those requiring additional insulin in line with standard clinical practice.The results showed that 46.9% of women with GDM were in the diet/lifestyle group and 53.1% were in the additional insulin therapy group; 45.3% were found to be obese. Good glycaemic control was achieved in both groups – mean pre‐delivery HbA1c was 41mmol/mol in the diet/lifestyle group versus 46mmol/mol in the insulin group (p<0.001). There was no statistically significant difference in the majority of the pregnancy outcome measures between the two groups. Those on diet‐only had a lower caesarean section rate (OR 0.39; 95% CI 0.26–0.58; p<0.001), a higher chance of vaginal birth (OR 2.40; 95% CI 1.62–3.56; p<0.001) and a lower chance of pre‐term labour (OR 0.49; 95% CI 0.31–0.76; p=0.001).It was concluded that good metabolic control is essential for successful pregnancy outcomes. The use of insulin does not appear to alter the maternal–fetal outcome in women with GDM. The early use of intervention in women on insulin requires further debate. Copyright © 2012 John Wiley & Sons.

Is there variation in health care for children and young people with cerebral palsy across the North of England? An audit of clinical practice

<h3>Aims</h3> To establish whether there is variation in health care for children and young people with cerebral palsy (CP) across the north of England. <h3>Methods</h3> Retrospective case note review of 389 children and young people registered on the North of England Collaborative Cerebral Palsy Survey (NECCPS) living in 15 geographical districts, born 1995-2002, with subsequent data validation by clinicians involved in their care. Data was collected on magnetic resonance imaging (MRI) of brain (marker of aetiological assessment), hips, spines, pain, growth, and nutrition. <h3>Results</h3> The audit sample was representative of all children and young people registered with the NECCPS across a range of clinical and demographic factors. 221/389 (56.8%) children and young people had an MRI overall, with significant variation (p&lt;0.001) in MRI rates between districts (figure 1). 259/389 (66.6%) had a discussion about pain recorded within the last 2 years. 110/126 (87.3%) cases where pain was present, had a management plan (figure 2). Those from the socio-economically most deprived quintile were significantly (p&lt;0.05) less likely to have had a discussion about pain than those in the least deprived quintile (figure 3). 69/373 (18.5%) had some degree of hip migration, of which 20.3% had complete hip dislocation. There was no record of hip status in 16/389 (4.1%). There was significant (p&lt;0.01) variation between districts in recording of state of spine; there was no record in 24.4% of the sample. 31/66 (47%) of those with a spinal curvature were monitored by a spinal surgeon and 54/353 (33.1%) had their hips monitored by an orthopaedic surgeon, with inter-district variation in access to spinal and orthopaedic surgeons. 35/383 (9.1%) had received gastrostomy for feeding but there was no difference in Body Mass Index between this group and the rest of the sample. Only for 60% of the sample, weight was recorded within the last year. 119/389 (31%) had weight percentiles ascertained and recorded with a significant (p&lt;0.001) inter-district variation (figure 4). <h3>Conclusion</h3> There is variation in important aspects of health care for children and young people with cerebral palsy across the north of England. There is a need to work towards more equitable health care for the best health outcomes.

The management of malignant ascites in Palliative care: An audit of clinical practice and development of standards and guidelines

BackgroundMalignancy is the underlying cause in approximately 10% of all cases of ascites. About 15–50% of patients with malignancy will develop ascites. Cancers commonly associated with the development of ascites...

A Clinical Audit of the Number of Vaginal Examinations in Labor: A NOVEL Idea

Clinical practice audits present an opportunity for providers to examine and reflect on their practice. Vaginal examinations are an integral part of intrapartum care but can be uncomfortable for women and can increase the risk of chorioamnionitis. Thus, vaginal examinations should be performed thoughtfully and for necessary reasons. A busy midwifery service at a large academic center underwent an audit of the number of vaginal examinations performed in labor for 205 women admitted in spontaneous labor or with spontaneous rupture of membranes. The retrospective chart audit was performed by research midwives who queried 2 electronic medical record databases, 1 for provider progress notes and 1 for nursing notes. On average, a woman underwent 4 vaginal examinations during labor, a rate greater than the World Health Organization recommendation of 1 examination every 4 hours during the first stage. The rate of presumed chorioamnionitis in this group of healthy, low-risk women was 6%, and women with this diagnosis averaged 7 vaginal examinations. After presentation and discussion of the audit findings, the midwives expressed appreciation for the opportunity to explore such a fundamental element of clinical practice and a heightened awareness of the importance of performing and documenting vaginal examinations. Audits of a similar nature in other midwifery practices are needed, as are studies exploring rates and possible modifiable causes of chorioamnionitis in low-risk women.

Using electronic clinical practice audits as needs assessment to produce effective continuing medical education programming

Background: The traditional needs assessment used in developing continuing medical education programs typically relies on surveying physicians and tends to only capture perceived learning needs. Instead, using tools available in electronic medical record systems to perform a clinical audit on a physician's practice highlights physician-specific practice patterns.Aim: The purpose of this study was to test the feasibility of implementing an electronic clinical audit needs assessment process for family physicians in Canada.Method: A clinical audit of 10 preventative care interventions and 10 chronic disease interventions was performed on family physician practices in Alberta, Canada. The physicians used the results from the audit to produce personalized learning needs, which were then translated into educational programming.Results: A total of 26 family practices and 4489 patient records were audited. Documented completion rates for interventions ranged from 13% for ensuring a patient's tetanus vaccine is current to 97% of pregnant patients receiving the recommended prenatal vitamins.Conclusions: Electronic medical record-based needs assessments may provide a better basis for developing continuing medical education than a more traditional survey-based needs assessment. This electronic needs assessment uses the physician's own patient outcome information to assist in determining learning objectives that reflect both perceived and unperceived needs.

Do topical antibiotics reduce exit site infection rates and peritonitis episodes in peritoneal dialysis patients? The Pan Thames Renal Audit

Peritonitis is the major cause of peritoneal dialysis (PD) technique failure. Prophylactic topical antibiotics have been reported to reduce peritoneal dialysis catheter exit site infections (ESI) and peritonitis rates. We audited the effect of different exit site practices in the 12 Pan Thames and South East England PD centres, on ESIs and peritonitis between 2005 and 2008. PD patients used prophylactic mupirocin (n=1,270), gentamicin (n=502) and no prophylactic antibiotics (n=1,203); annualised ESI rates were reduced with mupirocin (median 0.18, interquartile range [IQR] 0.13-0.23, patient episodes per year, vs. median 0.32, IQR 0.24-0.69, for no antibiotic prophylaxis, p<0.01). Gentamicin treatment was not significantly lower (median 0.29, IQR 0.21-0.47). Staphylococcal ESIs accounted for 39.6% in the no antibiotic group and fell to 25.7% with mupirocin and 28.2% with gentamicin. Despite the reduction in ESIs, there was no significant reduction in peritonitis rates (no antibiotics: median 0.56, IQR 0.5-0.65; mupirocin: median 0.55, IQR 0.53-0.75; and gentamicin: median 0.47, IQR 0.32-0.65). In particular, mupirocin did not reduce Staphylococcus aureus peritonitis rates. Topical antibiotics have been reported to reduce both ESI and peritonitis rates in controlled trials, and although in this audit of routine clinical practice, topical mupirocin did reduce overall ESI rates and both mupirocin and gentamicin reduced S. aureus ESIs, neither reduced overall peritonitis rates.

Biochemical Monitoring of Patients Treated with Antihypertensive Therapy for Adverse Drug Reactions

Biochemical monitoring of patients treated with antihypertensive therapy is recommended in order to identify potential adverse reactions to treatment. We aimed to review the literature investigating the nature of biochemical monitoring in adults treated in primary care with antihypertensive drugs. Specifically, we wished to establish (i) the proportion of patients with biochemical baseline testing prior to the initiation of antihypertensive therapy; (ii) the proportion of patients with biochemical monitoring after initiation of antihypertensive therapy; (iii) the patient characteristics associated with biochemical monitoring; (iv) the frequency of biochemical monitoring after the initiation of antihypertensive therapy; and (v) the relationship, if any, between biochemical monitoring and adverse patient outcomes. We searched MEDLINE, EMBASE and Google Scholar from 1948 to 31 December 2010 using a combination of text words and search terms. Retrospective and prospective cohort studies, cross-sectional studies, randomized controlled trials or quasi-randomized controlled trials, and audits of current clinical practice were included. Clinical trials, case reports and case series were excluded. Studies were included if they provided data on the proportion of patients treated with antihypertensive therapy in primary care who had any biochemical monitoring before or after the initiation of therapy. In total, 15 studies were included in our review, which used a wide variety of definitions of monitoring prior to and after the initiation of antihypertensive therapy. From 17% to 81% of patients treated with antihypertensive drugs had a baseline biochemical test and from 20% to 79% had any follow-up monitoring. In only 7 of the 12 studies that examined follow-up monitoring did more than half of the patients have any monitoring. Overall, this systematic review provides evidence that monitoring as recommended by published guidelines is not commonly undertaken. Only two studies were identified that examined patients with both baseline testing and follow-up monitoring. Omission of one or the other limits the ability to analyse the effect of treatment on electrolyte concentrations or renal function. There is limited research on the patient factors associated with monitoring and further work is required to determine the impact of monitoring on adverse patient outcomes. Important barriers to effective monitoring exist and this review emphasizes that these have not yet been overcome.

The Pregnant Motor Vehicle Accident Casualty

To investigate the workup/treatment provided to pregnant motor vehicle accident (MVA) casualties in a mature trauma system. Adherence to recommendations was used to measure quality of care. MVAs affect approximately 3% of pregnant women. Trauma casualty outcome improves after implementation of guidelines. A 5-year audit of clinical practice in 2 university hospitals with a trauma call system where the general surgeon is the primary care physician. Trauma guidelines (general/specific to treatment of pregnant MVA casualties) were used to examine adherence. Pregnant casualties aged >18 years, injured in a private vehicle were identified via computerized hospital databases. Data relevant to the study were extracted from ED/admission files. Among the 236 casualties included there were no maternal deaths. Six casualties (2.5%) had significant injuries and 3 (1.2%) required surgery (all within 24-hours of admission). Contrary to established procedure, maternal vital signs were often not documented. In contrast, fetal viability was usually documented; most casualties underwent ultrasound fetal evaluation (233 of 236, 98.7%) and those with viable pregnancies underwent fetal heart rate monitoring (162 of 169, 96%). A sixth of the MVA casualties (16%) were examined only by an obstetrician. All casualties were admitted but only 15 (6.4%) were admitted in accordance with guidelines. Readmission rates (1.3%) were similar to those observed in nonpregnant casualties. Pregnant MVA casualties are underexamined and overadmitted. Concerns regarding potential obstetrical complications distract medical attention away from basic trauma guidelines. Education programs should emphasize prioritizing the mother and adhering to the basic rules of trauma care despite the presence of the fetus.

Compliance with Good Clinical Practice in oncology registration trials in Japan

BackgroundThis study aimed to examine the quality in oncology registration trials for new drug application (NDA) or supplemental new drug application (sNDA) as extensions of the indications for use in Japan based on Good Clinical Practice (GCP) audit findings. Materials and methodsWe collected audit reports of on-site GCP inspections for registration trials in 383 NDAs or sNDAs that were reviewed by the Pharmaceuticals and Medical Devices Agency between the fiscal years 2004 and 2009. ResultsAmong the 40 audits for oncology drug applications, the frequencies at which one or more deficiencies ascribed to institution, investigator, sponsor, and institutional review board were found to be 15 (37.5%), 13 (32.5%), 21 (52.5%), and 10 (25.0%), respectively. The exclusion of patients from the review objective due to serious violations of GCP in 40 audits for oncology drug applications was observed in 2 (5.0%) cases, whereas that in the remaining 343 audits for other drug applications was observed in 40 (11.7%) cases. ConclusionThe overall compliance of GCP in oncology registration trials was moderately better than that in registration trials for other diseases, although there was no statistically significant difference between them.

Multiple sclerosis, from referral to confirmed diagnosis: an audit of clinical practice

Background: The National Institute for Health and Clinical Excellence (NICE) guidelines recommend a timeline of 6 weeks from referral to neurology consultation and then 6 weeks to a diagnosis of multiple sclerosis (MS). Objectives: We audited the clinical management of all new outpatient referrals diagnosed with MS between January 2007 and May 2010. Methods: We analysed the timelines from referral to first clinic visit, to MRI studies and lumbar puncture (LP) (if performed) and the overall interval from first visit to the time the diagnosis was given to the patient. Results: Of the 119 diagnoses of MS/Clinically Isolated Syndrome (CIS), 93 (78%) were seen within 6 weeks of referral. MRI was performed before first visit in 61% and within 6 weeks in a further 27%. A lumbar puncture (LP) was performed in 83% of all patients and was done within 6 weeks in 78%. In total, 63 (53%) patients received their final diagnosis within 6 weeks of their first clinic visit, with 57 (48%) patients having their diagnosis delayed. The main rate-limiting steps were the availability of imaging and LP, and administrative issues. Conclusions: We conclude that, even with careful scheduling, it is difficult for a specialist service to obtain MRI scans and LP results so as to fulfil NICE guidelines within the optimal six-week period. An improved service would require MRI scans to be arranged before the first clinic visit in all patients with suspected MS.

Musculoskeletal examination—an ignored aspect. Why are we still failing the patients?

Over the past two decades, rheumatologists from around the world have not only championed the musculoskeletal system examination but also modified the undergraduate teaching curriculum. This has led to the development and adoption of the gait, arms, legs and spine (GALS) screening along with regional examination techniques. The purpose of this study is to review current practice, determining the frequency of patient exposure to appropriate examination and confidence of junior doctors when dealing with MSK conditions. Two district-general hospitals (non-teaching) and one teaching hospital in North-East London were chosen. At each site, 50 patient notes were reviewed from the acute admission wards for medicine and surgery and the medical assessment unit. Factors considered included whether GALS screenings had taken place, documentation of MSK examinations and assessment of confidence of junior doctors in assessing MSK conditions. GALS screenings were performed for 4% of patients on the medical assessment unit, 7% of acute medical and 0% of acute surgical patients on admission. Examination of the MSK system yielded better results with 16%, 22% and 10% on each of the respective wards. Interviews with junior doctors found 10% routinely screening for MSK conditions, despite 87% feeling confident in taking MSK histories. This prospective audit of clinical practice highlights that patients failed to have a minimal assessment of the MSK system through GALS screenings. When examining the MSK system, results were somewhat better, although still fewer than expected. It is curious that the majority of junior doctors in training felt confident in dealing with MSK disease but few did it in practice. This begs the question of whether current teaching curricula and strategies are adequate. At a time where there is ever-increasing national momentum to address issues on obesity and cardiovascular health, our patients are still deprived of a standard MSK examination by the medical faculty.

Implementation of innovative pharmacogenetic tests into practice in Taiwan: an institutional perspective

AbstractPharmacogenetic tests are proposed as a means of targeting therapy to patients such that ineffective medicine prescription and adverse events are reduced and overall benefit in terms of improved health outcomes is maximized. However, the true impact of introducing pharmacogenetic tests into clinical practice remains to be confirmed. This commentary presents some of the key requirements in developing a pharmacogenetic clinical practice model in a hospital setting. The analysis considers the need to select carefully which pharmacogenetic tests are best offered, while balancing the cost to the institution given the potential benefits to the patient population base. Drawing on our experience in Taiwan, we recommend that developing a hospital task force for pharmacogenetic testing is a recommended approach to: (1) set quality standards on how best to conduct the test, (2) provide a pro forma for interpreting results, (3) prescribe treatment appropriately according to results, and (4) design an educational program for all relevant health care team members. To further support the implementation of pharmacogenetic testing in the hospital setting, it is necessary to promote audit of clinical practice by building hospital‐based registries to facilitate the collection of health care resource use and outcome data that records the clinical uptake of testing. We suggest that well‐conducted economic evaluations, relevant to local practice, are essential pieces of information to guide institutional decision making on how best to develop the appropriate use of pharmacogenetic tests in clinical practice. Drug Dev Res 71: 502–506, 2010. © 2010 Wiley‐Liss, Inc.

Implementation of a prolonged neonatal jaundice protocol supported by electronic software

PurposeSeveral audits of clinical practice have confirmed that there is insignificant yield from screening of prolonged jaundice babies with a wide range of tests including thyroid function test (TFT) and full blood count (FBC). This paper aims to audit local practice based on a newly adopted rationalised protocol of selective screening with split bilirubin supplemented with other investigations based on clinical risk assessment.Design/methodology/approachThe paper uses a retrospective audit of 50 babies referred for prolonged jaundice to a large district hospital in South West England. The authors also designed an easy‐to‐use, user‐friendly software application as a quick aid for implementation of the prolonged jaundice protocol.FindingsThe overall annual incidence of prolonged jaundice was 2.2 per cent of all live births. 32 patients (64 per cent) had only split biliburin test according to the protocol. In total 16 patients (32 per cent) had 18 tests requested unnecessarily including seven liver function test (LFT), eight FBC, one each of glucose, TFT and serum electrolytes. No patient with any serious liver disease was missed.Practical implicationsAppropriate recommendations for optimising the implementation of the current protocol based on the available scientific evidence were introduced.Originality/valueAfter two years of implementation of the protocol, it has been found to be cost‐effective and safe. The electronic software provides a useful prompt in guiding the investigation of prolonged jaundice.

Methods for determining disease burden and calibrating national surveillance data in the United Kingdom: the second study of infectious intestinal disease in the community (IID2 study)

BackgroundInfectious intestinal disease (IID), usually presenting as diarrhoea and vomiting, is frequently preventable. Though often mild and self-limiting, its commonness makes IID an important public health problem. In the mid 1990s around 1 in 5 people in England suffered from IID a year, costing around £0.75 billion. No routine information source describes the UK's current community burden of IID. We present here the methods for a study to determine rates and aetiology of IID in the community, presenting to primary care and recorded in national surveillance statistics. We will also outline methods to determine whether or not incidence has declined since the mid-1990s.Methods/designThe Second Study of Infectious Intestinal Disease in the Community (IID2 Study) comprises several separate but related studies. We use two methods to describe IID burden in the community - a retrospective telephone survey of self-reported illness and a prospective, all-age, population-based cohort study with weekly follow-up over a calendar year. Results from the two methods will be compared. To determine IID burden presenting to primary care we perform a prospective study of people presenting to their General Practitioner with symptoms of IID, in which we intervene in clinical and laboratory practice, and an audit of routine clinical and laboratory practice in primary care. We determine aetiology of IID using molecular methods for a wide range of gastrointestinal pathogens, in addition to conventional diagnostic microbiological techniques, and characterise isolates further through reference typing. Finally, we combine all our results to calibrate national surveillance data.DiscussionResearchers disagree about the best method(s) to ascertain disease burden. Our study will allow an evaluation of methods to determine the community burden of IID by comparing the different approaches to estimate IID incidence in its linked components.

A family medicine clerkship curriculum in medication errors

medical council approving the new course. The longterm aim of this change in the medical curriculum is to develop research-aware GPs who are able to engage in evidence-based medicine. What was done Each student is required to undertake a research project relevant to his or her placement community. Students are encouraged to identify local issues as topics and to discuss them with their teachers and university academic supervisors, who mentor their progress at all stages. Students are also required to apply for ethics approval for their projects and are given relevant information about research design. Finally, each student is required to write a formal report and disseminate his or her results to relevant stakeholders, peers and academics. Evaluation of results and impact The impact of the programme on the research capacity of the students will be evaluated using preand post-placement surveys. Ten areas of research will be investigated, namely: defining a research question or idea; writing a research protocol; finding relevant literature; critically reviewing literature; using quantitative research methods; using qualitative research methods; analysing and interpreting results; writing and presenting a research report; publishing results, and applying for research funding. The programme has the potential to increase understanding of local health issues in regional, rural and remote communities, to increase engagement with and acceptance of medical students in these communities, and to increase the engagement of the community in research. Moreover, GPs and students will have increased appreciation of the possibilities for undertaking research in their environment, regardless of location. Finally, successive cohorts of students may become involved in longitudinal research projects in the placement community, in which data collection is ongoing and survey analysis is undertaken annually. Currently, all students have selected their projects and have prepared proposals for submission to the university ethics committee. Areas of research chosen by the students include patients’ awareness of stroke symptoms, osteoporosis risk factors, choices for breast cancer treatments, clinical best practice audits, and patient willingness to allow medical students to be involved in the consultation process.

Welcome to Your New Look Journal

I’m pleased to announce some exciting changes to the journal for 2010. The New Year not only ushers in a new decade for us, but a new publisher too. The Royal Society of Medicine (RSM) Press has now taken over responsibility for producing Ultrasound, the Journal of the British Medical Ultrasound Society. Over the past few months, the editorial team has been working closely with RSM Press to develop the new journal cover and internal layout. Our journal is now once again in full colour with PDF and online versions of all articles available through HighWire. Another new feature available to the ultrasound community is the launch of free ‘virtual’ special issues. A paediatric issue and a vascular issue are available now and direct links can be found within the following guest editorials introducing these valuable resources. For those wishing to submit papers to Ultrasound, our new online manuscript submission system is exceptionally easy to use and can be found at http://mc.manuscriptcentral.com/ult. However, please don’t hesitate to get in touch with any one of the editorial team should you require further information about any aspect of our new look journal. This first issue for 2010 features a broad range of subjects as usual, but has particular emphasis on professional practice; I anticipate that my paper ‘Let’s all jump on the ultrasound bandwagon’ will elicit further debate on the use of ultrasound. In the absence of regulation, this ‘hot topic’ is likely to generate polar opinions among our readership, and we look forward to receiving your comments. Articles by Thiagarajah et al., Riley et al., and Robson and Wolstenhulme, all discuss the value and importance of audit in clinical practice. These audits are on, arguably, some of the most contemporary issues in UK departments: the battle against infection, sonographer-led MSK ultrasound and minimizing RSI (repetitive strain injury). Their findings and experiences are likely to provide useful guidance for other clinical departments. Original research includes an investigation into the ‘double aorta’ ultrasound artefact by Bull and Martin, and a study by Soo et al. discusses the use and limitations of ultrasound in the common condition of Morton’s neuroma. The Euroson 2009 congress held in Edinburgh in December was a huge success and comprised some excellent presentations from international experts. Many were on the value of performing contrast-enhanced ultrasound examinations. This technique is now well-established and continues to affirm its position as the imaging modality of choice in a range of clinical settings. Indeed, in some situations it outperforms CT and MR in terms of accuracy (see Trilaud et al. in this issue’s Echoes feature). Numerous live scanning workshops at the congress proved very popular by providing practical opportunities for many delegates. The programme was accompanied by manufacturers’ symposia and a large commercial exhibition. Sincere thanks to all those who contributed to this year’s meeting. The abstract booklet is included in this mailing. Finally, it gives me great pleasure to announce the winners of our two new competitions. Congratulations to Chloe Long, winner of the postgraduate journal prize for 2009. A PhD student at Loughborough University, Chloe wins a cash prize and a year’s subscription to BMUS. The judges felt all six entries were well-written and of the highest standard. However, Chloe’s paper ‘Interpreting echoes: why bats are better than ultrasound’, which was published in the February 2009 issue of Ultrasound, was fascinating, informative and ultimately proved to be the judges’ favourite. We are keen to continue to encourage early stage researchers to submit their work to the journal, and will be running this competition again during 2010. Please see the British Medical Ultrasound Society website (www.bmus.org) to read Chloe’s paper and for further competition details. Congratulations also to the four winners of the BMUS Visions Image competition kindly sponsored by Sony. They are Giovanni Camali, a veterinary surgeon from Venice, Joan Maycock, a gynaecology nurse from Dublin, Raniska Tente, a PhD student from Edinburgh, and Rizwan Patel, a medical student from Leicester. Each wins a Sony digital camera and a year’s subscription to BMUS. It is great to see that all our winners reflect the diversity of the ultrasound community and the breadth of our readership. Happy reading, Happy New Year and very best wishes to you all.

Carbon Dioxide Therapy in the Treatment of Cellulite: An Audit of Clinical Practice

BackgroundThe clinical practice of using carbon dioxide therapy for localized adiposities was audited over a 4-year period.MethodsPatients receiving physical, dietary, or drug concurrent therapy were excluded from the audit. Original measurements in terms of mean ± standard error of the mean (SEM) were compared with those obtained after five sessions.ResultsThis series included 101 women who underwent abdominal therapy. Significant reduction (p < 0.05) in mean upper, mid, and lower abdomen circumference was experienced by all three age groups: respectively, 1.8 ± 0.5, 1.6 ± 0.4, and 2.1 ± 0.3 cm in the 20- to 29-year- old group, 1.6 ± 0.4, 2.3 ± 0.3, and 2.1 ± 0.3 cm in the 30- to 39-year-old group, and 2.0 ± 0.4, 2.5 ± 0.4, and 2.6 ± 0.4 cm in the 40- to 50-year-old group. For 57 women who underwent localized thigh therapy (27 in the 20- to 29-year-old group, 18 in the 30- to 39-year-old group, and 12 in the 40- to 50-year-old group), thigh circumference was significantly reduced in the right versus left thigh: respectively, 1.6 ± 0.3 versus 1.5 ± 0.2 cm, 1.1 ± 0.3 versus 1.1 ± 0.3 cm, 1.6 ± 0.3 versus 1.5 ± 0.4. Weight loss was significant for older women who underwent abdominal therapy: 1.3 ± 0.2 kg in the 30- to 39-year-old group (n = 43) and 1.3 ± 0.2 kg in the 40- to 50 year-old group (n = 29). Older women who underwent thigh therapy also recorded significant weight reduction: 0.9 ± 0.4 kg in the 30- to 39-year-old group (n = 18) and 1.6 ± 0.3 kg in the 40- to 50-year-old group (n = 12). The results for 10 men were not significant.ConclusionThese results agree with those reported originally and demonstrate that carboxytherapy is safe and effective.