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Objective: Ankyloglossia is characterized by an abnormally short lingual frenulum, which impairs tongue movement. Ankyloglossia has been related to craniofacial growth disturbances and dental malocclusion. But even though there is a clear biological plausibility for this hypothesis, available evidence is scarce., Methods: A case-control design was followed. Patients between 4 and 14 years old were routinely screened for short lingual frenulum and recruited from the pediatric Otolaryngology consultation of 3 Spanish tertiary referral hospitals. Lingual frenulum was assessed with the Marchesan system. A cohort of cases with short lingual frenulum and a cohort of healthy controls matched for sex and age were included. Both cases and controls had pictures of occlusion. Occlusion was evaluated by an expert in orthodontics, blinded for the frenulum assessment., Results: A total of 100 participants were included, 70 males and 30 females. The proportion of malocclusion in the short lingual frenulum group was 48%, while it was 24% in the normal frenulum group. The odds ratio of malocclusion for the short lingual frenulum patients was 2.92 (CI 95% 1.15-7.56). The difference was statistically significant (p=.012). This difference was significant for patients with class III occlusion (p=.029). There was no difference for patients with class II (p=.317)., Conclusions: This work supports the hypothesis that relates class III malocclusion with a short lingual frenulum., (Copyright © 2021 Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: The efficacy of postexposure prophylaxis (PEP) after human immunodeficiency virus (HIV) contact relies on administering the treatment within 4 hours of contact with the virus. This study aimed to evaluate predictors of the time that elapses between HIV exposure and emergency department arrival., Material and Methods: Prospective observational study carried out at Hôpital Bichat, a university teaching hospital in Paris, France. All emergency visits for occupational or nonoccupational exposure to HIV in 2016 and 2017 were included., Results: A total of 1475 cases were studied; 598 patients responded to the follow-up survey. A delay of 4 hours or more between HIV exposure and the emergency department visit was associated with type of contact: health care occupational exposure, other occupational exposure, or sexual intercourse (P .001). We found significant differences between individuals exposed during sexual contact versus occupational exposure with respect to knowledge of the PEP program pathway (65.2% vs 46.9%, respectively), previous use of PEP (23.9% vs 13.1%), alcohol intake (36.2% vs 18.5%), drug use (34.6% vs 8.6%), and chemsex (sexualized drug use) (26.1% vs 0%) (P .001, all comparisons). Predictors of time until start of PEP among individuals exposed during sexual intercourse were knowledge and prior use of the PEP pathway (P .001), drug use (P = .03), and chemsex (P .001). Predictors among occupationally exposed individuals were prior knowledge of the PEP pathway and drug use (P .001)., Conclusion: Delay in seeking PEP after HIV exposure is greater among individuals exposed during sexual intercourse. Knowledge of the PEP program and prior use of it are associated with less delay. Exposure during sexual intercourse, alcohol and drug use, and chemsex are associated with longer delays, especially in men who have sex with men.

Osteoporosis (OP) and chronic kidney disease (CKD) both independently affect bone health. A significant number of patients with CKD have decreased bone mineral density (BMD), are at high risk of fragility fractures and have an increased morbidity and mortality risk. With an ageing population, these observations are not only dependent on "renal osteodystrophy" but also on the associated OP. As BMD predicts incident fractures in CKD patients (partI), we now aim to analyse the potential therapeutic consequences. Post-hoc analyses of randomised studies have shown that the efficacy of drugs such as alendronate, risedronate, raloxifene, teriparatide and denosumab is similar to that of the general population in patients with a mild/moderate decline in their glomerular filtration rate (especially CKD-3). These studies have some flaws however, as they included mostly "healthy" women with no known diagnosis of CKD and generally with normal lab test results. Nevertheless, there are also some positive preliminary data in more advanced stages (CKD-4), even though in CKD-5D they are more limited. Therefore, at least in the absence of significant mineral metabolism disorders (i.e. severe hyperparathyroidism), the potential benefit of these drugs should be considered in patients with a high or very high fracture risk. It is an important change that the new guidelines do not make it a requirement to first perform a bone biopsy and that the risk/benefit ratio of these drugs may be justified. However, we must also be aware that most studies are not consistent and the level of evidence is low. Consequently, any pharmacological intervention (risk/benefit) should be prudent and individualised., (Copyright © 2019 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: To demonstrate an effect of 1 year of training using immersive simulations repeated every 6 weeks versus every 6 months to improve the performance of multidisciplinary teams (MDTs) working with children in lifethreatening situations., Material and Methods: Randomized controlled trial in 12 MDTs of emergency responders in France. Each MDT consisted of 4 persons: a physician, a resident, a nurse, and the ambulance driver. Six MDTs participated in 9 different high-fidelity simulations of pediatric shock over the course of a year. Six control MDTs were presented with 3 of the experimental group's simulations at 3 time points (starting point, 6 months, and 1 year). Technical performance was assessed with the Team Average Performance Assessment Scale (TAPAS) and an intraosseous (IO) access performance scale. Nontechnical performance assessment instruments were the Clinical Teamwork Scale (CTS) and, for leadership, the Behavioral Assessment Tool (BAT). Progress over time was analyzed by comparing the 2 groups during the 3 simulations they experienced in common., Results: Performance scores rose significantly over the study period in the experimental group (P=.01 for the TAPAS score, P=.008 for IO access, P=.03 for the CTS score, and P=.02 for the BAT score) but did not change in the control group (P=.46 for TAPAS, P=.55 for IO access, P=.62 for CTS, and P=.58 for BAT). All mean (SD) scores were higher in the experimental group than in the control group in the last session: TAPAS, 55.8 ± 6.3 vs 31.2 ± 10.3, P=.01; IO access, 91.7 ± 8.0 vs 62.9 ± 16.2, P=.01; CTS, 63.2 ± 9.3 vs 47.2 ± 13.1, P=.03; and BAT, 72.8 ± 5.1 vs 51.2 ± 14.3, P=.01). The 6-month assessment showed significant between-group differences on 2 technical performance measures (P=.02 for TAPAS and P=.03 for IO access); the experimental group's scores were higher. We also observed close correlations between the performance of the leader and the group on both nontechnical (rho > 0.9) and technical (rho > 0.7) assessments., Conclusion: Simulation-based training should be repeated more than 3 times per year. Our findings suggest the advisability of repeating simulations of infrequent, high-risk scenarios every 6 weeks to improve all performance scores and guarantee acceptable technical and nontechnical performance throughout the year.

Osteoporosis (OP) and chronic kidney disease (CKD) independently influence bone and cardiovascular health. A considerable number of patients with CKD, especially those with stages 3a to 5D, have a significantly reduced bone mineral density leading to a high risk of fracture and a significant increase in associated morbidity and mortality. Independently of classic OP related to age and/or gender, the mechanical properties of bone are also affected by inherent risk factors for CKD ("uraemic OP"). In the first part of this review, we will analyse the general concepts regarding bone mineral density, OP and fractures, which have been largely undervalued until now by nephrologists due to the lack of evidence and diagnostic difficulties in the context of CKD. It has now been proven that a reduced bone mineral density is highly predictive of fracture risk in CKD patients, although it does not allow a distinction to be made between the causes which generate it (hyperparathyroidism, adynamic bone disease and/or senile osteoporosis, etc.). Therefore, in the second part, we will analyse the therapeutic indications in different CKD stages. In any case, the individual assessment of factors which represent a higher or lower risk of fracture, the quantification of this risk (i.e. using tools such as FRAX ® ) and the potential indications for densitometry in patients with CKD could represent an important first step pending new clinical guidelines based on randomised studies which do not exclude CKD patients, all the while avoiding therapeutic nihilism in an area of growing importance., (Copyright © 2018 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: To analyze data recorded in the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments), which collects information on the clinical characteristics and laboratory findings of patients with acute heart failure (AHF) treated in 29 Spanish hospital emergency departments (EDs) as well as therapies used and clinical course. We analyzed changes in management observed over time and compared the results with data recorded in other AHF registries., Material and Methods: Prospective multicenter cohort study of consecutive patients treated in 3 different years: 2007, 2009, and 2011. We collected demographic, clinical, and laboratory data; medications taken prior to the emergency and in the ED; and outcome variables (in-hospital and 30-day and 1-year mortality rates, readmissions within 30 days). Changes in therapy and course in the 3 years were analyzed. The literature was reviewed to find other national and international AHF registries., Results: A total of 5845 patients were included (2007, 948; 2009, 1483; 2011, 3414). The mean age was 79 years and 56% were women. The AHF episode registered was the first experienced by 34.6% of the patients. Comorbidity was high: 82% had hypertension, 42.3% had diabetes mellitus, and 47.7% had atrial fibrillation. Severe or total functional dependence was observed in 21.9%, and 57.3% had systolic dysfunction (left ventricular ejection fraction, 38.3%). The main treatments administered consisted in diuretics (96.8%), endovenous nitroglycerine (20.7%), noninvasive ventilation (6.4%), and inotropic agents or vasopressors (3.6%). The glomerular filtration rate was low in 57%. Troponin and natriuretic peptide levels were measured in the EDs in 49.1% and 42.4% of the cases, respectively. Patients presented as normotensive in 66.4% of the cases, hypertensive in 23.5%, and hypotensive in 4.6% (0.7% in shock); 76.1% were admitted (1.9% to the ICU). The median hospital stay was 7 days and 23.9% were discharged from the ED. In-hospital mortality was 7.6%; 30-day mortality was 9.4% and 1-year mortality 29.5%. Orders for troponin and natriuretic peptide determinations increased over the 3 study periods, and the intravenous infusion of diuretics and inotropic agents and vasoconstrictors decreased (P < 0.001, all comparisons). Revisits within 30 days also decreased (P = 0.004). No changes were observed in in-hospital or 30-day mortality rates between 2007 and 2011. We reviewed 14 previously published registry reports (8 compiled prospectively); only 2 of the registries included ED patients., Conclusion: The EAHFE registry describes the characteristics of AHF in a cohort that resembles the universe of our patients with AHF. Significant changes were observed over time in some aspects of AHF management. Revisits decreased, but mortality rates remained unchanged. Only 2 other previously analyzed registries included patients with AHF treated in hospital EDs.

The management of ureteropelvic junction (UPJ) obstruction has evolved over the past 20 years in response to the development of new technology. Open surgery is still the reference standard against which all other surgical interventions must be measured. The surgical approach has, however, gone through rapid changes, and the open procedure initially described has evolved considerably. Endoscopic and laparoscopic approaches have largely supplanted open pyeloplasty for the majority of primary ureteropelvic junction obstruction cases. Laparoscopic approaches provide a balance between a highly successful technique in all patients and improved postoperative recovery. It has been shown to improve postoperative outcomes with shorter recovery times and hospital stays, and to provide equivalent functional results with a success rate of 95%. Nevertheless, laparoscopic pyeloplasty is not a simple procedure. There are a certain number of disadvantages, such as the limited range of laparoscopic instrument movement, the two dimensional image, the unfamiliar hand-eye coordination and the relatively inefficient ergonomic position. Since 2000, however, robots have provided a magnified three-dimensional view giving a greater degree of freedom. This system has simplified suturing and has improved precision of the operating technique. However, the system is very expensive and, providing it is available in their institution, it seems easier for beginners to learn the robotic technique. Additionally, it has similar success rates (both radiological and clinical) to those obtained with open techniques.