Antibiotic Prophylaxis For Dental Procedures Research Articles

Antibiotic prophylaxis for dental procedures after joint arthroplasty: a cross-sectional survey of orthopaedic surgeons about current practices

Background: Periprosthetic joint infection is a rare, but potentially devastating complication that can occur after prosthetic joint replacement. In 2016, the American Academy of Orthopaedic Surgeons (AAOS) revised its Appropriate Use Criteria (AUC) for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. The objective of this study was to survey orthopaedic surgeons regarding their use of prophylactic antibiotics in arthroplasty patients undergoing dental procedures. Additionally, the authors inquired whether surgeons who have undergone arthroplasty procedures themselves practice the antibiotic prophylaxis when faced with decisions regarding their own joints. Methods: The authors surveyed currently practicing orthopaedic surgeons in the United States who perform joint arthroplasty procedures. The questions pertained to demographic data, training background, type of employment, arthroplasty type and volume, antibiotic prophylaxis practices, and awareness of the AAOS/American Dental Association (ADA) recommendations. Results: Two hundred, fourteen surveys were completed, though not all respondents answered every question. Most surgeons (149 of 200, 74.5%) routinely recommend prophylactic antibiotics for all patients with total joint arthroplasties who undergo dental procedures. The majority of the surgeons (163 of 199, 81.9%) reported that they are aware of the current AAOS/ADA guidelines, but that did not have a substantial effect on whether they routinely recommend prophylactic antibiotics (P=0.74). Conclusions: Most orthopaedic surgeons surveyed said they understand the AAOS/ADA guidelines, but that they routinely prescribe prophylactic antibiotics for arthroplasty patients undergoing dental procedures. These prescribing practices have no significant relationship with their knowledge of the AAOS AUC, years of experience, volume, specialty, employment, or personal history of joint replacement. Level of Evidence: Level IV, cross-sectional survey

Antibiotic prophylaxis for dental procedures: do dental students know enough?

Introduction According to the American Heart Association (AHA) the cardiac conditions with the highest risk of infective endocarditis (IE) for which antibiotic prophylaxis (AP) is reasonable are: prosthetic cardiac valves, previous IE, congenital heart disease and cardiac transplantation recipients [1,2]. The aim of this study was to analyse the knowledge of AP in Dental Medicine students. Materials and methods A prospective and analytical study was conducted using a questionnaire designed to describe the knowledge of AP and covering issues such as: AP guidelines, dental procedures and medical conditions needing AP, and recommended antibiotics. A 0–10 score was attributed to the questionnaire and the correct answers were based on AHA guidelines. The questionnaire was applied to students of the two last curricular years (4th and 5th year) of a Master in Dental Medicin and to newly graduated trainees at a University Dental Clinic – both in the Greater Lisbon area. The questionnaire was authorised by the students through a declaration of informed consent. This study was authorised by the Clinical Director of CDEM and approved by Egas Moniz Ethics Committee. Results A total of 275 questionnaires were obtained with an answer rate of: 93.8%/4th year (n = 135), 84.5%/5th year (n = 120) year and 57.1%/trainees (n = 20). The median score of the questionnaire was 6.0, 6.4 and 6.8 for 4th and 5th year students and trainees, respectively. The results were more satisfactory regarding: guideline existence knowledge, high-risk conditions recommended for AP and antibiotic selection in non beta lactam allergic patients. Unsatisfactory answers were related to: dental procedures in need of AP, heart conditions associated with IE, and antibiotic selection in beta lactam allergic patients. Noteworthy, antibiotic selection and dental procedure knowledge was significantly better in postgraduates. Discussion and conclusions The knowledge of the undergraduates and newly graduates concerning AP for dental procedures was not totally satisfactory, however there was a positive evolution according to the academic degree. As pharmacology subjects are taught in the early years of the course, antibiotic therapeutics should be reinforced later during the study cycle, and students should be made aware of the importance of a rational and adequate use of antibiotics in dental practice. There is a need to improve the knowledge and communication over this topic not only among undergraduates but also regarding postgraduates, in order to encourage clearer and more homogeneous antibiotic prescription patterns.

Antibiotic prophylaxis and immune-compromised patients

On the basis of the arguments found in the literature for and against prescribing antibiotic prophylaxis for dental procedures in immunecompromised patients, dental care providers are advised not to prescribe antibiotic prophylaxis to this group of patients when they undergo dental treatment, unless it concerns an exceptional case. Such cases comprise immune-compromised patients considered to have a high risk of developing systemic infections when undergoing invasive dental procedures, including extractions or implant placement. These are patients with, for example, severe neutropenia, patients with a primary immune deficiency, or patients who use high doses of immunosuppressants or very strong immunosuppressants. There is little evidence in the literature about the use of antibiotic prophylaxis for this specific group of patients. Such evidence is, however, also difficult to obtain because it concerns a small group of patients.

Unnecessary Antibiotic Prophylaxis for Dental Procedures is Widespread.

According to this study.

\u2018Caveat emptor\u2019: the cautionary tale of endocarditis and the potential pitfalls of clinical coding data\u2014an electronic health records study

BackgroundDiagnostic codes from electronic health records are widely used to assess patterns of disease. Infective endocarditis is an uncommon but serious infection, with objective diagnostic criteria. Electronic health records have been used to explore the impact of changing guidance on antibiotic prophylaxis for dental procedures on incidence, but limited data on the accuracy of the diagnostic codes exists. Endocarditis was used as a clinically relevant case study to investigate the relationship between clinical cases and diagnostic codes, to understand discrepancies and to improve design of future studies.MethodsElectronic health record data from two UK tertiary care centres were linked with data from a prospectively collected clinical endocarditis service database (Leeds Teaching Hospital) or retrospective clinical audit and microbiology laboratory blood culture results (Oxford University Hospitals Trust). The relationship between diagnostic codes for endocarditis and confirmed clinical cases according to the objective Duke criteria was assessed, and impact on estimations of disease incidence and trends.ResultsIn Leeds 2006–2016, 738/1681(44%) admissions containing any endocarditis code represented a definite/possible case, whilst 263/1001(24%) definite/possible endocarditis cases had no endocarditis code assigned. In Oxford 2010–2016, 307/552(56%) reviewed endocarditis-coded admissions represented a clinical case. Diagnostic codes used by most endocarditis studies had good positive predictive value (PPV) but low sensitivity (e.g. I33-primary 82% and 43% respectively); one (I38-secondary) had PPV under 6%. Estimating endocarditis incidence using raw admission data overestimated incidence trends twofold. Removing records with non-specific codes, very short stays and readmissions improved predictive ability. Estimating incidence of streptococcal endocarditis using secondary codes also overestimated increases in incidence over time. Reasons for discrepancies included changes in coding behaviour over time, and coding guidance allowing assignment of a code mentioning ‘endocarditis’ where endocarditis was never mentioned in the clinical notes.ConclusionsCommonly used diagnostic codes in studies of endocarditis had good predictive ability. Other apparently plausible codes were poorly predictive. Use of diagnostic codes without examining sensitivity and predictive ability can give inaccurate estimations of incidence and trends. Similar considerations may apply to other diseases. Health record studies require validation of diagnostic codes and careful data curation to minimise risk of serious errors.

Patient perceptions of antibiotic prophylaxis for dental procedures after total joint arthroplasty

ObjectiveInvestigating patients’ perceptions regarding need for antibiotic prophylaxis during dental procedures after undergoing joint arthroplasty. MethodsQuestionnaire was administered to patients presenting at: 1)an orthopaedic office; 2)a dental office; regarding perceptions of antibiotic prophylaxis. Results36 orthopaedic patients responded “Yes” to always taking prophylaxis; 36 patients responded “No” (36/72, 50.0% compliance). Five dental patients responded “Yes” to always taking prophylaxis; 19 patients responded “No” (5/24, 20.8% compliance) (p = 0.017). 67/135 orthopaedic patients (49.6%) endorsed some form of dental prophylaxis, versus 34/58 dental patients (58.6%) (p = 0.27). ConclusionPatient perceptions of the need for dental prophylaxis vary within orthopaedic and dental practices.

Antibiotic prophylaxis for dental procedures.

Patients at risk of developing infective endocarditis or infection of a prosthetic joint may require antibiotic prophylaxis during dental treatment. Current guidelines recommend prophylaxis less often than in the past. This is because of concerns about antimicrobial resistance and an increased understanding about the daily incidence of bacteraemia. There is international variation in the recommendations for preventing infective endocarditis so Australian health professionals should consult Australian guidelines. Conditions for which prophylaxis is still recommended include prosthetic heart valves and rheumatic heart disease in patients at high risk of endocarditis. Most experts no longer recommend antibiotic prophylaxis for dental procedures in patients with prosthetic joints.

Looking Beyond Gastrointestinal Bleed to Diagnose Hereditary Hemorrhagic Telangiectasia (HHT)

A 60 year old male presented to our Gastroenterology clinic to establish care for history of recurrent upper gastrointestinal (GI) bleed over the past 12 years. The initial episode manifested as fatigue due to anemia. Evaluation with upper endoscopy had revealed several bleeding gastric Arteriovenous Malformations (AVMs) which were successfully cauterized. He had required repeated endoscopic therapy of the bleeding gastric AVMs every 18 to 24 months. Upon additional questioning, he reported repeated self-limiting epistaxis since the age of 3 years. A thorough physical exam revealed large telangiectases on his tongue, with multiple smaller ones on the inner margin of his lips and on the periungual fingertips. Laboratory testing revealed anemia and normal liver chemistries. He met clinical criteria (Curaçao criteria) for diagnosis of ‘definite’ HHT, which is diagnosed when at least 3 of the 4 clinical criteria (telangiectasias, epistaxis, visceral AVMs or family history of HHT) are present. Despite multiple previous endoscopic procedures and clinic visits, this was the first time he had been told he might have a genetic syndrome causing his illness. He was scheduled for deep enteroscopy which revealed AVMs in small intestine which were cauterized. Otolaryngology evaluation revealed telangiectases on nasal septal mucosa. He was offered genetic testing and also scheduled for screening with a brain MRA and Transthoracic contrast echocardiogram (TTCE).Figure 1Figure 2Figure 3HHT, also known as Osler-Weber Rendu disease, is an uncommon autosomal dominant disease caused by abnormal blood vessel development. HHT is a clinical diagnosis or can also be diagnosed by genetic testing. Chronic GI bleed is managed by iron supplementation, endoscopic therapy (argon plasma coagulation is preferred) and systemic hormonal or antifibrinolytic therapy in selected patients. Screening with brain MRA for Cerebrovascular malformations (CVMs) and TTCE for Pulmonary AVMs (PAVMs) is recommended. PAVMs can present as paradoxical embolization and CVMs may manifest as headaches, seizures or bleeding. Patients with documented PAVMs and those not yet screened must get antibiotic prophylaxis for dental procedures and avoid SCUBA diving. This case exemplifies Sir William Osler's best known saying, “Listen to your patient, he (she) is telling you the diagnosis”. HHT is underdiagnosed and a thorough history and exam will lead to timely diagnosis and prevention of complications.

Antibiotic prophylaxis prescribing practices of dentists in Singapore

Infective endocarditis is a serious complication that results in significant morbidity and mortality in susceptible patients. The guidelines for antibiotic prophylaxis have been updated by the American Heart Association and National Institute for Health and Clinical Excellence. The antibiotic prophylaxis prescribing practices among dentists in Singapore are unknown. To determine the specific infective endocarditis antibiotic prophylaxis prescribing practices of dentists in Singapore. A questionnaire survey was sent through an email link and by postal mail. Statistical analysis was carried out using SPSS 19.0. Responses were received from 458 dentists (34.3% response rate), of which 278 (65.9%) were general practitioners. The majority of respondents (39.8%) followed the American Heart Association 2007 guidelines and 30.2% followed cardiologists' recommendations. The accuracy of prescriptions for 13 cardiac conditions and 12 dental procedures were evaluated. The median number of accurate answers for cardiac conditions was eight for the American Heart Association 1999 guidelines, and four for the American Heart Association 2007 and National Institute for Health and Clinical Excellence guidelines, respectively. The median number of accurate answers for dental procedures was generally high, both for dentists who followed the American Heart Association 1999 guidelines (median=10) and American Heart Association 2007 (median=9) guidelines. Majority of respondents (82.8%) felt that developing a local guideline would be beneficial to the local dental community. Dentists were accurate in their prescriptions of antibiotic prophylaxis for dental procedures, but not for cardiac conditions. It may be helpful to attain a consensus among local cardiologists and dentists to unify the antibiotic prophylaxis prescription practices in Singapore.

Prevention of Late PJI

The definition of late PJI is variable in literature. Majority of the members of the consensus felt that any infection occurring after one year should be considered as late. Coventry defined stages of PJI, where Stage I is an acute infection that occurred within 3 months of the index procedure, Stage II is a delayed infection that occurred between 3 months and 2 years after the index procedure where there was no pain-free interval, and Stage III is a hematogenous infection where there is a pain-free stage [1]. Garvin and Hanssen defined a late chronic PJI as one that occurred 4 weeks after the index procedure with an insidious clinical onset [2]. McPherson et al defined a chronic infection as one that had symptoms for 4 weeks or longer [3]. In Sweden, a late PJI is defined as one that occurs 2 years after the index procedure. Due to the huge variation in time frames, we did not find consensus in defining a timeframe for a late PJI. However, we classified late PJI as late hematogenous PJI, where there was an asymptomatic period followed by clinical and/or radiographical signs of infection. The workgroup feels that late PJI arises as a result of bacteremia at a later stage [4] and should be distinguished with infections arising as a result of intraoperative contamination. Risk factors for late PJI are similar to those described for PJI in Workgroup 1 (Please see Question 1, Workgroup 1).

Antibiotic Prophylaxis for Dental Procedures at Risk of Causing Bacteremia Among Post-Total Joint Arthroplasty Patients: A Survey of Canadian Orthopaedic Surgeons and Dental Surgeons

To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P<0.0001). Both groups nonetheless recognize the importance of treatment within 2-years post-TJA as per AAOS/ADA guidelines. However, greater duration of practice pointed to potential inadequacy of these guidelines based on reported experience with late-hematogenous infection post-TJA. While discrepancies in attitude toward antibiotic-prophylaxis between surgeon groups remain, both groups agreed that the evidence to support decision making regarding antibiotic-prophylaxis for TJA patients undergoing dental procedures remains inadequate.

Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis

The 2007 American Heart Association (AHA) guidelines for the prevention of infective endocarditis (IE) called for a major reduction in the number of patients recommended for antibiotic prophylaxis (AP) and redefined the dental procedures considered to put these patients at risk of acquiring the infection. The purpose of the authors' study was to determine the acceptance of these changes among and the impact of the changes on dentists and their patients. The authors sent a survey to a random sample of 5,500 dentists in the United States. Ninety-five percent of the 878 respondents indicated that they saw patients who receive AP. More than 75 percent were either satisfied or very satisfied with the AHA guidelines, and the respondents indicated that they believed almost three-quarters of their patients also were pleased. Seventy percent of dentists, however, had patients who took antibiotics before a dental procedure even though the guidelines no longer recommend it. Acceptance of the 2007 guidelines appears to be high, but controversy remains. Additional scientific data are needed to resolve these issues. The 2007 AHA guidelines have greatly simplified the identification of patients who need AP for dental procedures, given that, in general, far fewer people with cardiac abnormalities are considered to be at risk as a result of invasive procedures. Some physicians, however, continue to prescribe antibiotics for some patients whom the AHA no longer considers to need them. Patients also may choose to continue this practice themselves. There is ongoing controversy surrounding this common clinical question in dental practice, and the next guidelines from the AHA may change on the basis of data from future clinical studies.

Drug cost implications for antibiotic prophylaxis for dental procedures

To determine the potential economic impact from the practice of antibiotic prophylaxis for dental procedures. We estimated the prevalence of patients in the United States with 15 medical conditions and devices. We multiplied the prevalence for each patient population by the percentage of specialists recommending prophylaxis, then by the estimated number of dental office visits per year, and then by an average pharmacy cost to arrive at a total estimated range of annual cost for this practice. The 15 medical conditions and devices included in the present study involve upward of 20 million people and an estimated annual cost between $19,880,279 and $143,685,823. The actual cost may be far greater because of an underestimation of these prevalence figures and the use of antibiotic prophylaxis for additional patient populations. Our data suggest a significant cost for antibiotic prophylaxis in the dental practice setting and the need for evidence-based recommendations concerning this practice.

Antibiotic Prophylaxis for Dental Procedures

The possibility that bacteremia from the mouth could cause infective endocarditis (IE) was first suggested >100 years ago, and it was later reinforced by others who targeted the viridans group streptococci from poor oral hygiene and dental extractions.1–3 These observations, along with the advent of antibiotics, eventually led to the first guidelines from the American Heart Association (AHA) in 1955. Antibiotic prophylaxis (AP) became the primary focus for prevention of IE and a standard of care for countries around the world. Controversy concerning efficacy and safety issues has existed for >30 years, and there has been a progressive reduction in the patient populations and the procedures suggested for AP since that time. Of concern, and in spite of a decreasing emphasis on AP for cardiac patients, upwards of 25 noncardiac patient populations are recommended for AP by some clinicians out of concern for systemic infections that might originate from dental procedures (eg, prosthetic joints).4 Article see p 60 Significant differences in recommendations from experts in the United States, United Kingdom, and other countries over the years highlight the lack of convincing data to either support or reject this practice. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom issued new recommendations in 2006, which took the bold step of eliminating AP altogether.5 Current (2007) AHA guidelines narrow the focus to only 4 cardiac groups at higher risk for a bad outcome from IE but who represent ≈10% of all people at risk for IE.6 The AHA-defined moderate-risk groups represent ≈90% of people at risk for IE, all of whom were recommended for AP before 2007. There are, therefore, no …

Infecciones orales y endocarditis infecciosa

Revised guidelines for the prevention of infective endocarditis published by national and international associations in the last years do not support the indiscriminate use of antibiotic prophylaxis for dental procedures. However, some of them still recommend its use in high-risk patients before dental treatments likely to cause bleeding. Given the high prevalence of bacteremia of dental origin due to tooth-brushing, mastication or other daily activities, it appears unlikely that infective endocarditis from oral microorganisms can be completely prevented. A good oral health status and satisfactory level of oral hygiene are sufficient to control the consequences of the systemic spread of oral microorganisms in healthy individuals. However, caution is still needed and prophylactic antibiotics must be administered to susceptible or medically compromised patients. This review briefly outlines the current concepts of odontogenic bacteremia and antibiotic prophylaxis for patients undergoing dental treatment.

Antibiotic Prophylaxis for Dental Procedures to Prevent Indwelling Venous Catheter-related Infections

Antibiotic Prophylaxis for Dental Procedures to Prevent Indwelling Venous Catheter-related Infections

Antibiotic Prophylaxis for Dental Procedures to Prevent Indwelling Venous Catheter-related Infections

Background Chronic indwelling central venous catheters are used commonly for a variety of indications. A predominant limitation of their use is catheter-related infections. Some clinicians believe that bacteremia from an invasive dental procedure could cause catheter-related infections and that antibiotic prophylaxis may prevent this complication. The topic is controversial, in large part because of the lack of clinical trial data supporting this notion. Methods We performed a systematic review to determine the level of evidence to support this practice. We retrieved studies, guidelines, recommendations, case reports, and editorials on prescribing prophylactic antibiotic therapy for indwelling central venous catheters before oral/dental procedures, using a search of PubMed, National Guideline Clearinghouse, and textbooks. Results There were no clinical trials and no documented cases of a catheter-related infection associated with an invasive dental procedure. Despite the lack of evidence, there are numerous recommendations and guidelines available in the literature that support the administration of “dental” prophylaxis. Conclusion There is no evidence to support the administration of prophylactic antibiotics to prevent catheter-related infections associated with an invasive oral procedure in patients with chronic indwelling central venous catheters.

Odontogenic Infections in the Etiology of Infective Endocarditis

Revised guidelines for the prevention of infective endocarditis published by the American Heart Association in 2007 do not support the indiscriminate use of antibiotic prophylaxis for dental procedures. However, they still recommend the use of prophylaxis for high-risk patients before dental treatments likely to cause bleeding. Given the high prevalence of bacteremia of dental origin due to tooth-brushing, mastication or other daily activities, it appears unlikely that infective endocarditis from oral microorganisms can be completely prevented. A good oral health status and satisfactory level of oral hygiene are sufficient to control the consequences of the systemic spread of oral microorganisms in healthy individuals. However, caution is still needed and prophylactic antibiotics must be administered to susceptible or medically compromised patients. This review briefly outlines the current concepts of odontogenic bacteraemia and antibiotic prophylaxis for patients undergoing dental treatment.

Viridans streptococcal (Streptococcus intermedius) mitral valve subacute bacterial endocarditis (SBE) in a patient with mitral valve prolapse after a dental procedure: The importance of antibiotic prophylaxis

Subacute bacterial endocarditis (SBE) is an infection of the heart involving damaged valves or endothelium. The most common organisms causing SBE are the viridans streptococci. Viridans streptococci differ in their propensity to cause SBE, which is related to the ability to adhere to damaged heart valves and endothelium, which is a function of extracellular matrix production. Streptococcus intermedius is a member of the S. anginosus group. S. intermedius is one of the many strains of viridans streptococci and a rare cause of SBE. SBE may result following a high-grade, sustained veridans streptococcal bacteremia in patients with predisposing cardiac lesions. Because viridans streptococci are relatively avirulent pathogens in normal hosts, they usually present as SBE. Some strains of viridans streptococci are inherently more virulent (eg, S. intermedius) and clinically resemble S. lugdunensis or S. aureus. We report a case of S. intermedius SBE in a patient with mitral valve prolapse (MVP). Throughout the patient's life, she received antibiotic prophylaxis for dental procedures and never developed SBE. Because of changes in endocarditis prophylaxis guidelines in 2007, recommending no prophylaxis for dental procedures in patients with MVP, she did not receive prophylaxis for a dental procedure 3 months before admission. The change in prophylaxis recommendations was based on the relatively low incidence of endocarditis with certain cardiac lesions. The recommendations were also based on concern for antibiotic resistance from widespread antibiotic use for antibiotic prophylaxis. There has been no appreciable increase in penicillin resistance, and antimicrobial resistance is not an important consideration among the viridans streptococci. The incidence of SBE is not high after dental procedures in patients with MVP, but if SBE occurs, it may result in serious consequence for the patient. In this case, the patient developed S. intermedius, mitral valve SBE complicated by a cerebral vascular accident, and embolic occlusion of her leg. She was given optimal antibiotic treatment with ceftriaxone 2 g (intravenously) every 24 hours plus gentamicin 120 mg (intravenously) every 24 hours (synergy dose) but failed to respond to antimicrobial therapy. Although her S. intermedius bacteremia was rapidly cleared with antimicrobial therapy, sterilization of her vegetation was not accomplished, and during therapy, the size of her cardiac vegetation actually increased in size. Because of therapeutic failure despite optimal antibiotic therapy, the increasing size of her vegetation necessitated mitral valve replacement, which the patient underwent. Reasons for apparent/real antibiotic failure include inappropriate antimicrobial therapy, inadequately dosed antimicrobial therapy, antibiotic "tolerance," or increased pathogen virulence. Her strain of S. intermedius was sensitive to all antibiotics and not due to a "tolerant strain", i.e., her minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) were the same (<0.25 microg/mL). In this case, despite optimal antimicrobial therapy, and in the absence of resistance/tolerance, therapeutic failure was best explained on the basis of S. intermedius virulence. The take-home lesson for clinicians is that it is better to err on the side of antibiotic prophylaxis even in patients with low-risk cardiac lesions. Failure to administer antibiotic prophylaxis for dental procedures may result in SBE and have disastrous consequences for the patient, which, in this case, resulted in a cerebral vascular accident, embolic occlusion of the leg, and mitral valve replacement. In terms of virulence in patients with endocarditis, S. intermedius may resemble S. lugdenesis.

Paediatric cardiology: Looking back, looking forward

With the publication of Maude Abbott’s Atlas of Congenital Cardiac Disease in 1936, the field of paediatric cardiology was born in Canada, but in those early days, it was understandably confined to the description and taxonomy of heart defects in the young. Since that time, the reliable palliation and repair of increasingly complex cardiac conditions has become commonplace, and simple survival is no longer the only goal; with the increasing number of survivors, there is an increasing need to ensure long-term quality of life. Coinciding with these changes has been the growing realization that children born with healthy hearts are in danger of acquiring cardiovascular risk factors that were found exclusively in adults in past generations. There are children and youth with heart disease, and at risk of heart disease, in every paediatric and primary care practice in Canada. With these thoughts in mind, we welcome you to the Cardiology focus issue of Paediatrics & Child Health. You will not find articles on classification, reviews of surgical procedures or images of the latest catheter technologies in the present issue. Instead, we have gathered manuscripts that cover a variety of topics of interest to child and youth health care providers, including a collaborative approach to diagnosis, current outcomes for complex patients and thought-provoking controversies in management and prevention strategies. The realities of our country’s geography (and our profession’s numbers) have necessitated innovative means of communication and collaboration to bring diagnostic expertise to patients with suspected heart disease, wherever they may be. In the first article, Dr John Finley gives us an introduction to a Canadian success story – the Maritime telecardiology program ( pages 156–158). The earlier diagnosis and institution of treatment that this program offers is one of many ways that paediatricians can positively influence outcomes in complex congenital heart disease, especially for those in rural areas. Earlier diagnosis is one reason that patient outcomes have improved; other reasons include ever-evolving techniques of catheter intervention, cardiac surgery and the associated pre- and postoperative care. We counsel families not only on the short-term expectations of these procedures, but also need to address families’ questions and uncertainties that extend well beyond the first catheterization, the first surgery and the first outpatient visit. Dr Derek Human provides a comprehensive update on current outcomes for these patients, providing answers for paediatricians for families’ questions not only about life expectancy, but also about the quality of that life ( pages 161–166). As the survival rate increases, new fields of enquiry emerge, such as the effects of physical activity on children with heart disease. This is a subject that prompts questions from parents, schools and patients themselves. Moola et al ( pages 167–170) explains the demonstrated benefits for the majority, the occasions when restrictions are appropriate and the need for further exploration of this rapidly changing area of medicine. Children with congenital heart disease will experience a number of firsts that parallel those of their nonaffected peers: first steps, first words, first teeth and a first visit to the dentist. The recent change in antibiotic prophylaxis for dental procedures has come under scrutiny and has given rise to new questions and debates, perhaps more in terms of the philosophy underlying the change, rather than the pragmatics of its application. The point-counterpoint provided by Drs Marie Beland ( pages 171–172) and Roland Beaulieu ( pages 173–175) provides differing viewpoints on this topic. In addition to dealing with the increasing frequency and complexity of congenital heart disease patients in paediatric practice, child and youth health practitioners are now being faced with the challenges of the rising epidemic of obesity and the secondary complications that ensue. Diseases once considered to be adult-onset are now being diagnosed in children, introducing a whole new era in the practice of paediatric medicine. Dr Tracey Bridger’s overview ( pages 177–182) provides paediatricians with practical information to guide investigation, management and prevention of these complications. The sudden death of a young person, particularly one without a history of known heart disease, is a tragedy on multiple levels, and seizes both media and medical attention. These apparently healthy young people, who may have undiagnosed cardiomyopathies, conduction defects or other conditions, have no idea that they are at risk. Limited resources lead to debate about the most effective methods of prevention and intervention; Drs Stuart Berger ( pages 183–184) and Robert Gow ( pages 185–188) reflect on two possible approaches to saving lives. We trust that you, the reader, will find the articles informative, thought-provoking and will join us in thanking the authors, reviewers and staff at Paediatrics & Child Health for their hard work on the present issue. We hope that the diversity of topics discussed will make this theme issue a continuing reference for all.