Procedures In People Research Articles

Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions.

Minor oral surgery or dental extractions (oral or dental procedures) are widely performed and can be complicated by hazardous oral bleeding, especially in people with an inherited bleeding disorder such as haemophilia or Von Willebrand disease. The amount and severity of singular bleedings depend on disease-related factors, such as the severity of the haemophilia, both local and systemic patient factors (such as periodontal inflammation, vasculopathy or platelet dysfunction) and intervention-related factors (such as the type and number of teeth extracted or the dimension of the wound surface). Similar to local haemostatic measures and suturing, antifibrinolytic therapy is a cheap, safe and potentially effective treatment to prevent bleeding complications in individuals with bleeding disorders undergoing oral or dental procedures. However, a systematic review of trials reporting outcomes after oral surgery or a dental procedure in people with an inherited bleeding disorder, with or without, the use of antifibrinolytic agents has not been performed to date. The primary objective was to assess the efficacy of local or systemic use of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures. Secondary objectives were to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or Von Willebrand disease and to further establish the effects of these agents on bleeding in oral or dental procedures for each of these populations. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches of the Cochrane Central Register of Controlled Trials (CENTRAL), of MEDLINE and from handsearching of journals and conference abstract books. We additionally searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and The Cochrane Library. Additional searches were performed in ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP).Date of last search of the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 14 December 2015. Randomised and quasi-randomised controlled trials in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained for potentially relevant abstracts and two authors independently assessed these for inclusion based on the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. While there were no eligible trials in people with Von Willebrand disease identified, two randomised, double-blind, placebo-controlled trials (total of 59 participants) in people with haemophilia undergoing dental extraction were included. One trial of tranexamic acid published in 1972 included 28 participants with mild, moderate or severe haemophilia A and B and one of epsilon aminocaproic acid published in 1971 included 31 people with haemophilia with factor VIII or factor IX levels less than 15%. Overall, the two included trials showed a beneficial effect of tranexamic acid and EACA, administered systemically, in reducing the number of bleedings, the amount of blood loss and the need for therapeutic clotting factor concentrates. Regarding postoperative bleeding, the tranexamic acid trial showed a risk difference of -0.64 (95% confidence interval -0.93 to - 0.36) and the EACA trial a risk difference of -0.50 (95% confidence interval 0.77 to -0.22). The combined risk difference of both trials was -0.57 (95% confidence interval -0.76 to -0.37), with the quality of the evidence (GRADE) for this outcome is rated as moderate. Side effects occurred once and required stopping epsilon aminocaproic acid (combined risk difference of -0.03 (95% CI -0.08 to 0.13). There was heterogeneity between the two trials regarding the proportion of people with severe haemophilia included, the concomitant standard therapy and fibrinolytic agent treatment regimens used. We cannot exclude that a selection bias has occurred in the epsilon aminocaproic acid trial, but overall the risk of bias appeared to be low for both trials. Despite the discovery of a beneficial effect of systemically administered tranexamic acid and epsilon aminocaproic acid in preventing postoperative bleeding in people with haemophilia undergoing dental extraction, the limited number of randomised controlled trials identified, in combination with the small sample sizes and heterogeneity regarding standard therapy and treatment regimens between the two trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in oral or dental procedures in people with haemophilia. No trials were identified in people with Von Willebrand disease.

Clinical triage for colonoscopy is useful in young women.

Colonoscopy is an invasive procedure and a limited resource. It is therefore desirable to restrict its use to those in whom it yields an important diagnosis, without missing pathology in others. The aim of this study was to determine whether standard clinical criteria can be used to reliably distinguish when colonoscopy is advisable in women 30 years and younger. A retrospective audit was performed at a single centre of 100 consecutive colonoscopies performed in women 30 years old and younger. The indications for the colonoscopy were recorded, and divided into clear and relative indications. The primary outcome of whether an endoscopic diagnosis was made was compared between the two groups. Clear indications for colonoscopy included overt rectal bleeding, elevated inflammatory markers, anaemia, iron deficiency and strong family history of colorectal cancer. Relative indications included abdominal pain or discomfort, bloating and altered bowel habit/motions. The average age was 23 years. Sixty women had both relative and clear indications. Eleven had only clear indications and 28 only relative indications. Altogether, 58 colonoscopies were normal, and 17 showed inflammatory bowel disease. No subject with only relative indications had an abnormal finding (0/28). The diagnostic yield was significantly different between those with only relative indications (0%) versus those with at least one clear indication (59%; P < 0.0001). Standard clinical criteria can be used to restrict safely the use of colonoscopy in young women. This will avoid performing procedures in people without clear indications, saving costs, resources and complications.

How safe is metabolic/diabetes surgery?

Although recent studies have shown the impressive antidiabetic effects of laparoscopic Roux-en-Y gastric bypass (LRYGB), the safety profile of metabolic/diabetes surgery has been a matter of concern among patients and physicians. Data on patients with type 2 diabetes who underwent LRYGB or one of seven other procedures between January 2007 and December 2012 were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database and compared. Of the 66 678 patients included, 16 509 underwent LRYGB. The composite complication rate of 3.4% after LRYGB was similar to those of laparoscopic cholecystectomy and hysterectomy. The mortality rate for LRYGB (0.3%) was similar to that of knee arthroplasty. Patients who underwent LRYGB had significantly better short-term outcomes in all examined variables than patients who underwent coronary bypass, infra-inguinal revascularization and laparoscopic colectomy. In conclusion, LRYGB can be considered a safe procedure in people with diabetes, with similar short-term morbidity to that of common procedures such as cholecystectomy and appendectomy and a mortality rate similar to that of knee arthroplasty. The mortality risk for LRYGB is one-tenth that of cardiovascular surgery and earlier intervention with metabolic surgery to treat diabetes may eliminate the need for some later higher-risk procedures to treat diabetes complications.

Antibiotics for the prophylaxis of bacterial endocarditis in dentistry

Infective endocarditis is a severe infection arising in the lining of the chambers of the heart with a high mortality rate.Many dental procedures cause bacteraemia and it was believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries have recommended that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, recent guidance by the National Institute for Health and Care Excellence (NICE) in England and Wales has recommended that antibiotics are not required. To determine whether prophylactic antibiotic administration, compared to no such administration or placebo, before invasive dental procedures in people at risk or at high risk of bacterial endocarditis influences mortality, serious illness or the incidence of endocarditis. The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 21 January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE via OVID (1946 to 21 January 2013) and EMBASE via OVID (1980 to 21 January 2013). We searched for ongoing trials in the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/). No restrictions were placed on the language or date of publication when searching the electronic databases. Due to the low incidence of BE it was anticipated that few if any trials would be located. For this reason, cohort and case-control studies were included where suitably matched control or comparison groups had been studied. The intervention was the administration of antibiotic, compared to no such administration, before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those individuals at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received or not. Included case-control studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest were mortality or serious adverse events requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who developed endocarditis. Two review authors independently selected studies for inclusion then assessed risk of bias and extracted data from the included study. No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over two years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines, and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxies). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days, and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes. There remains no evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically, practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

Contemplación artística con personas que sufren trastorno psicótico y del estado de ánimo Aportaciones para un arteterapia receptivo

This paper analyses the theoretical foundations of art receptive procedures for people with psychotic illness on the base of the “iconic turn” discourse in recent aesthetic theory. Fundamental axioms (such as the “surplus value” of the picture, its resemblance of reality; the role of the observer in the process of reception) are discussed in realtion to the perceptive changes that accompany psychotic illness. Important correlations are established between the nature of the picture (constance, protective function, creation of an “other” or “opposite”, reality-detail) and the necesssity to reorganise and restabilise the overpowering effects of psychotic perception in individuals and their contact to reality. The theoretical aspects are discussed with examples of practical work.

Sentence comprehension disorders in aphasia: The concept of chance performance revisited

Background: In behavioural tests of sentence comprehension in aphasia, correct and incorrect responses are often randomly distributed. Such a pattern of chance performance is a typical trait of Broca's aphasia, but can be found in other aphasic syndromes as well. Many researchers have argued that chance behaviour is the result of a guessing strategy, which is adopted in the face of a syntactic breakdown in sentence processing. Aims: Capitalising on new evidence from recent studies investigating online sentence comprehension in aphasia using the visual world paradigm, the aim of this paper is to review the concept of chance performance as a reflection of a syntactic impairment in sentence processing and to re-examine the conventional interpretation of chance performance as a guessing behaviour. Main Contribution: Based on a review of recent evidence from visual world paradigm studies, we argue that the assumption of chance performance equalling guessing is not necessarily compatible with actual real-time parsing procedures in people with aphasia. We propose a reinterpretation of the concept of chance performance by assuming that there are two distinct processing mechanisms underlying sentence comprehension in aphasia. Correct responses are always the result of normal-like parsing mechanisms, even in those cases where the overall performance pattern is at chance. Incorrect responses, on the other hand, are the result of intermittent deficiencies of the parser. Hence the random guessing behaviour that persons with aphasia often display does not necessarily reflect a syntactic breakdown in sentence comprehension and a random selection between alternatives. Instead it should be regarded as a result of temporal deficient parsing procedures in otherwise normal-like comprehension routines. Conclusion: Our conclusion is that the consideration of behavioural offline data alone may not be sufficient to interpret a performance in language tests and subsequently draw theoretical conclusions about language impairments. Rather it is important to call on additional data from online studies that look at language processing in real time in order to gain a comprehensive picture about syntactic comprehension abilities of people with aphasia and possible underlying deficits.

Abstract P091: Temporal Trends in Incidence of Acute Myocardial Infarction and Revascularization in People With and Without Mental Illness

Objective: The objective of this study was to evaluate the temporal trends in the incidence of acute myocardial infarction (AMI) and receipt of revascularization procedures in people with and without mental illness. Hypothesis: Individuals with mental illness will have higher rates of AMI, and lower rates of revascularization compared to people without mental illness. Methods: We did a population-based study using provincial administrative data from April 1, 1998 until March 31, 2009. We identified individuals 20 years of age and older as having mental illness (psychotic disorder [PD] or mood disorder [MD]) based on physician billing claims and hospitalization data, and compared them to those without mental illness by this definition. We identified incident AMI using a validated algorithm applied to hospitalization data. We used procedure codes to identify receipt of cardiac catheterization, coronary artery bypass grafting (CABG), or percutaneous transluminal coronary angioplasty (PTCA) in those with incident AMI. Rates were age-adjusted using the 2001 Canadian census population to perform direct standardization. Relative change over time was calculated by comparing rates in 2009 to rates in 1998. Results: A total of 3,639,480 subjects were included, of whom 576,411 (15.8%) had a mood disorder only, 38,116 (1.0%) had a psychotic disorder only, and 72,430 (2.0%) had both a MD and PD. People with MD were more likely to be female, whereas those with PD were older, than the other mentally ill and non-mentally ill populations. Incidence of AMI was highest in people with PD (210 per 100,000 in 2009) and lowest in people without mental illness (160 per 100,000 in 2009), however, incidence of AMI decreased over time in all groups. Use of catheterization decreased over time in people with MD (19% relative decrease) and PD (25% relative decrease), while increasing in people without mental illness (10.8% relative increase). Use of PTCA increased in all groups except people with PD (21.1% relative decrease). Conclusions: Incidence of AMI decreased over time in people with and without mental illness, however, people with mental illness consistently had a higher incidence of AMI compared to individuals without mental illness. Use of catheterization and PTCA increased in people without mental illness while decreasing in people with PD over the study period.

For Justice, there must be a More Powerful PCC

The solicitor believes the body overseeing press regulation requires greater resources and wider powers if it is to be more effective. And the law must offer cheaper and simpler procedures for people who take legal action.

Trends in lower extremity surgical and endovascular revascularization in Germany

We analyzed trends in lower extremity endovascular and open surgical procedures in hospitalized patients in Germany. We used national statistics (DRG statistics) published by the Federal Statistical Office including data from almost all hospitals in Germany to calculate annual procedure rates of lower extremity endovascular and open surgical procedures in the years 2005 to 2008. Detailed lists of the OPS-codes 8 - 836, 5 - 381, 5 - 393 separated by the 6th number of the code were analyzed regarding procedures representing revascularization of peripheral arteries including the aorta. Between 2005 and 2008 the total number of endovascular procedures increased from 73,584 to 98,664 and the number of surgical procedures from 74,789 to 86,172 a year. Age-adjusted incidence rates of endovascular procedures in people >= 65 years increased from 325 to 432 per 100,000 while the incidence rates of all open surgical procedures increased from 315 to 351 per 100.000. Looking only at bypass surgery the incidence remained unchanged with 177 and 176 per 100,000 in the same period. Endovascular procedures other than balloon angioplasty including percutaneous atherectomy, laser recanalization or usage of cutting balloon, account for less than 1 % in Germany. The numbers of endovascular procedures overweigh the numbers of open surgical procedures for treatment of lower extremity PAD in Germany today. In contrast to data from the USA we could not demonstrate a decrease of open surgical procedures in Germany in recent years.

Risk and rewards of fecal transplants

The “yuck” factor alone compels many to instinctively want to wash their hands, and/or wash their hands of it. A Calgary, Alberta, doctor performs the procedure in people’s homes, to avoid administrative squabbles with local health officials. A Burnaby, British Columbia hospitalist is now

Socioeconomic inequalities in the diffusion of health technology: Uptake of coronary procedures as an example

This paper examines socioeconomic lags in the diffusion of high technology health care, focusing on the diffusion of coronary procedures in people with ischaemic heart disease. Using linked hospital and mortality data, we studied patients admitted to Western Australian hospitals with a first admission for acute myocardial infarction between 1989 and 2003 (n=27,209). An outcome event was the receipt, within a year, of a coronary procedure-angiography, angioplasty and/or coronary artery bypass surgery (CABG). Socioeconomic status (SES) was assigned to each individual using the SEIFA Index of Disadvantage. Cox regression was used to model the association between SES and procedure rates in five consecutive three-year time periods. Angiography and CABG showed socioeconomic lags in diffusion, with rates peaking earlier in higher SES patients, such that the inequality patterns were consistent with the inverse equity hypothesis. The evidence for a lag in diffusion for angioplasty was weaker. Overall, that there is some evidence for a lag in diffusion of health technology indicates that it is essential to consider trends over time when examining the equity impact of health technologies.

Prescription of Antibiotics for Prophylaxis to Prevent Bacterial Endocarditis

Systematic review conclusion. There is no evidence that antibiotic prophylaxis before dental procedures is effective or ineffective against bacterial endocarditis in patients already at risk of developing the disease.Critical summary assessment. On the basis of evidence from one case-control study, no definite conclusion can be drawn on the usage of antibiotic prophylaxis before dental procedures.Evidence quality rating. Limited. Does prophylactic antibiotic administration before invasive dental procedures in people at increased risk of bacterial endocarditis influence mortality, serious illness or endocarditis incidence? The authors conducted a comprehensive search of six electronic databases from 1950 through June 2008. The initial search identified 980 abstracts of which the authors reviewed 118 full articles. The authors excluded 83 articles because they were discussion articles, editorials or guidelines and 34 articles because they were duplicate studies. They included one article, which was a case-control study. The one study that was included reported on all cases of endocarditis in the Netherlands during a two-year period from November 1986 through November 1988, according to the authors. In the study, the authors defined cases as patients who had a predisposing cardiac disease and had undergone a medical or dental procedure with a definite or possible indication for prophylaxis and developed endocarditis within 180 days of this procedure. In the study, control patients had one of the following pre-existing conditions: congenital heart defect, history of rheumatic fever, high risk of developing endocarditis with prosthetic heart valves or a history of endocarditis. Control patients were matched for age and had undergone a medical or dental procedure with a definite or possible indication for prophylaxis and had not developed endocarditis within 180 days of the procedure. Indications for “definite prophylaxis” were dental extraction and “dental root work,” and an indication for “possible prophylaxis” was dental scaling. Of 349 patients who developed native-valve endocarditis, 44 had undergone dental treatment with a definite or possible indication for prophylaxis. Seven of these patients had been treated with prophylactic antibiotics before the dental procedure. Of the patients meeting the criteria for the control group, 181 had undergone a dental procedure with a definite or possible indication for prophylaxis. Seventeen of the control patients had been administered prophylactic antibiotics before they underwent the dental procedure. The odds of development of endocarditis among those receiving antibiotic prophylaxis was 1.62 (95 percent confidence interval, 0.57–4.57). The authors did not locate any studies that assessed mortality, illness or other adverse effects. Since no conclusive evidence supporting a benefit was identified, the authors did not look for information on harms. There is no evidence that antibiotic prophylaxis is effective or ineffective against bacterial endocarditis when it is administered before an invasive dental procedure in people who are at risk of developing the disease.

Trends in cardiovascular admissions and procedures for people with and without diabetes in England, 1996–2005

The aim of this study was to compare 10-year trends in admissions, with and without diabetes recorded, for myocardial infarction, angina, stroke, percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG). We used national hospital-activity data in England collected between 1996 and 2005 and compared trends in admissions, after adjusting for age, sex and area-level deprivation. Overall, there was a modest fall in the number of admissions for angina and little change in the numbers of admissions for myocardial infarction (MI) and stroke. From 1996/1997 to 2005/2006, the numbers of admissions with diabetes recorded rose for each of MI, angina and stroke; the proportion of admissions with type 2 diabetes recorded rose from 7.2% to 13.9% for MI, from 6.7% to 15.3% for angina and from 6.2% to 11.3% for stroke. Over the 10-year period, after adjusting for age, sex and deprivation, the number of admissions for CABG rose about threefold; for PCI, the number of admissions with diabetes recorded rose 15-fold, compared with a fourfold increase in the number of admissions with diabetes not recorded. We found significant increases in the numbers of admissions with type 2 diabetes recorded for major cardiovascular events and procedures, which has important financial and public-health implications. Better prevention of type 2 diabetes in at-risk patients and aggressive cardiovascular risk-factor management in current patients with diabetes is needed.

G‐PASS: an instance‐oriented security infrastructure for Grid travelers

AbstractGrid computing unifies distributed resources via its support for the creation and use of virtual organizations (VOs), where a VO represents a collection of distributed resources to be accessed through predefined resource sharing and coordination policies. We consider a special type of mobile processes, named Grid travelers, which can travel across boundaries of VOs for the detection of resource availability, to negotiate for the approval of access privileges and to conduct remote execution. A new security infrastructure named G‐PASS is proposed to guarantee the validity and integrity of the travelers and the critical security knowledge they collect while traveling, especially while crossing some VOs. G‐PASS borrows the idea of passport and custom, as well as the procedures for people's travel in real life, to provide role‐based delegation mapping and access control. We demonstrate the power and feasibility of G‐PASS with a simulated mobile agent environment and a distributed ray‐tracing application running on multiple VOs. Various security overheads coming from migration decisions and actual agent or process migration are reported. G‐PASS can be installed with Grid Security Infrastructure (GSI) as the base, which makes it compatible with the existing Grid middleware. Copyright © 2006 John Wiley &amp; Sons, Ltd.

Penicillins for the prophylaxis of bacterial endocarditis in dentistry.

Many dental procedures cause bacteraemia and it is believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries recommend that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, it is unclear whether the potential risks of this prophylaxis outweigh the potential benefits. To determine whether prophylactic penicillin administration compared to no such administration or placebo before invasive dental procedures in people at increased risk of BE influences mortality, serious illness or endocarditis incidence. The search strategy was developed on MEDLINE and adapted for use on the Cochrane Oral Health, Heart and Infectious Diseases Groups' Trials Registers (to October 2003), as well as the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2002), OLDMEDLINE (1966 to June 2002); EMBASE (1980 to June 2002); SIGLE (to June 2002); and the Meta-register of current controlled trials. Due to the low incidence of BE it was anticipated that few if any trials would be located. For this reason, cohort and case controlled studies were included where suitably matched control or comparison groups had been studied. The intervention was the administration of penicillin compared to no such administration before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received. Included case control studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest were: mortality or serious adverse event requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who develop endocarditis. Two reviewers independently selected studies for inclusion, then assessed quality and extracted data from the included study. No RCTs, CCTs or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over 2 years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxys). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes. There is no evidence about whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support published guidelines in this area. It is not clear whether the potential harms and costs of penicillin administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

How does minor renal dysfunction influence cardiovascular risk and the management of cardiovascular disease?

This review focuses on the association between mild renal insufficiency (stage 2 and 3 of chronic kidney disease) and cardiovascular disease and discusses therapeutic options. Although the association of chronic renal insufficiency and cardiovascular risk was first shown in patients with end-stage renal disease, even minor renal dysfunction is now established as an independent risk for atherosclerotic cardiovascular disease. The association has been established in patients with a high cardiovascular risk but also in the general population. Treatment with angiotensin-converting enzyme inhibitors and statins can reduce cardiovascular morbidity and mortality in patients with renal insufficiency. Coronary revascularization improves the prognosis in patients with minor renal dysfunction, but there is still an underutilization of coronary revascularization procedures in people with renal insufficiency. The use of coronary stenting has now reduced the incidence of restenosis in these patients, and there is hope that the development of new devices will improve the prognosis in patients with renal insufficiency as well. Nevertheless, people with cardiovascular disease and renal insufficiency die significantly more often than people without renal insufficiency independent of prior successful treatment. Further investigations should focus on the causes of and possible preventive interventions for the staggering cardiovascular risk in the ever-increasing number of people with minor renal dysfunction.

Decreasing incidence of major amputations in people with diabetes.

To assess the results of the strategy used in avoiding major amputations in patients with diabetes mellitus. A retrospective study for the years 1981 to 1995 in a central district hospital in Copenhagen with a catchment area population of about 178,000. There were 463 major leg amputations and the incidence decreased from 27.2 to 6.9/100,000 population (75%). The decrease in patients with Type I (insulin-dependent) diabetes mellitus was from 10.0 to 4.1 (59%) and in Type II (non-insulin-dependent) diabetes mellitus from 17.2 to 2.8/100,000 people (84%). Analysis showed that the diabetic population remained constant despite a considerable fall in the number of older people. During the study period infra-popliteal arterial bypass was introduced for the treatment of critical lower limb ischaemia and in diabetic patients the number of bypasses increased from zero to 13/100,000 population. The total number of revascularisation procedures in people with diabetes increased from 2.6 to 19.2/100,000 population. Moreover, a multidisciplinary diabetic foot clinic was established. A 75% reduction in the incidence of major amputations coincided with a sevenfold increase in revascularization procedures and the establishment of a multidisciplinary diabetic foot clinic suggesting these measures are important in the prevention of diabetic leg amputations.

General Practice Recruitment for People at Risk of Schizophrenia: The Buckingham Experience

Objective The process of detecting people at high risk of schizophrenia from a community sample is a major challenge for prevention of psychotic disorders. The aim of this paper is to describe early detection procedures that can be implemented in primary care settings. Methods A selected literature review is supplemented by experiences and data obtained during the Buckingham Integrated Mental Health Care Project. Results General medical practitioners have been favoured as the agents most likely to prove helpful in detecting the key risk factors that predict the onset of schizophrenic disorders, as well as in recognising the earliest signs and symptoms of these conditions. However, the practical problems of screening for multiple and subtle risk factors in general practice are substantial, and general practitioners (GPs) often have difficulty recognising the earliest signs of a psychotic episode. A range of strategies to assist GPs detect early signs of psychosis in their patients are considered. Conclusions It is feasible to implement primary care setting early detection procedures for people at risk of schizophrenia. Implementation is aided by the use of a brief screening questionnaire, training sessions and case supervision; and increased collaboration with mental health services and other community agencies.