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Objective: To summarize the epidemiology and outcomes of children with multiple organ dysfunction syndrome as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26–27, 2015). Data Sources: Literature review, research data, and expert opinion. Study Selection: Not applicable. Data Extraction: Moderated by an experienced expert from the field, issues relevant to the epidemiology and outcomes of children with multiple organ dysfunction syndrome were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. Data Synthesis: Summary of presentations and discussion supported and supplemented by the relevant literature. Conclusions: A full understanding the epidemiology and outcome of multiple organ dysfunction syndrome in children is limited by inconsistent definitions and populations studied. Nonetheless, pediatric multiple organ dysfunction syndrome is common among PICU patients, occurring in up to 57% depending on the population studied; sepsis remains its leading cause. Pediatric multiple organ dysfunction syndrome leads to considerable short-term morbidity and mortality. Long-term outcomes of multiple organ dysfunction syndrome in children have not been well studied; however, studies of adults and children with other critical illnesses suggest that the risk of long-term adverse sequelae is high. Characterization of the long-term outcomes of pediatric multiple organ dysfunction syndrome is crucial to identify opportunities for improved treatment and recovery strategies that will improve the quality of life of critically ill children and their families. The workshop identified important knowledge gaps and research priorities intended to promote the development of standard definitions and the identification of modifiable factors related to its occurrence and outcome.

AimsLoss or absence of proximal femoral bone in revision total hip arthroplasty (THA) remains a significant challenge. While the main indication for the use of proximal femoral replacements (PFRs) is in the treatment of malignant disease, they have a valuable role in revision THA for loosening, fracture and infection in patients with bone loss. Our aim was to determine the clinical outcomes, implant survivorship, and complications of PFRs used in revision THA for indications other than malignancy.Patients and MethodsA retrospective review of 44 patients who underwent revision THA using a PFR between 2000 and 2013 was undertaken. Their mean age was 79 years (53 to 97); 31 (70%) were women. The bone loss was classified as Paprosky IIIB or IV in all patients. The mean follow-up was six years (2 to 12), at which time 22 patients had died and five were lost to follow-up.ResultsThe mean Harris Hip Score improved from 42.8 (25.9 to 82.9) pre-operatively to 68.5 (21.0 to 87.7) post-operatively (p = 0.0009). A total of two PFRs had been revised, one for periprosthetic infection eight years post-operatively and one for aseptic loosening six years post-operatively. The Kaplan-Meier survivorship free of any revision or removal of an implant was 86% at five years and 66% years at ten years. A total of 12 patients (27%) had a complication including six with a dislocation.ConclusionPFRs provide a useful salvage option for patients, particularly the elderly with massive proximal femoral bone loss who require revision THA, with significant clinical improvement. While the survivorship of the implant is good at five years, dislocation continues to be the most common complication. The judicious use of larger femoral heads, dual-mobility constructs, or constrained liners may help to minimise the risk of dislocation. Cite this article: Bone Joint J 2017;99-B:325–9.

Abstract Lung tissue remodeling in chronic obstructive pulmonary disease (COPD) is characterized by airway wall thickening and/or emphysema. Although the bronchial and alveolar compartments are functionally independent entities, we recently showed comparable alterations in matrix composition comprised of decreased elastin content and increased collagen and hyaluronan contents of alveolar and small airway walls. Out of several animal models tested, surfactant protein C (SPC)-TNF-α mice showed remodeling in alveolar and airway walls similar to what we observed in patients with COPD. Epithelial cells are able to undergo a phenotypic shift, gaining mesenchymal properties, a process in which c-Jun N-terminal kinase (JNK) signaling is involved. Therefore, we hypothesized that TNF-α induces JNK-dependent epithelial plasticity, which contributes to lung matrix remodeling. To this end, the ability of TNF-α to induce a phenotypic shift was assessed in A549, BEAS2B, and primary bronchial epithelial cells, and phenotypic markers were studied in SPC–TNF-α mice. Phenotypic markers of mesenchymal cells were elevated both in vitro and in vivo, as shown by the expression of vimentin, plasminogen activator inhibitor-1, collagen, and matrix metalloproteinases. Concurrently, the expression of the epithelial markers, E-cadherin and keratin 7 and 18, was attenuated. A pharmacological inhibitor of JNK attenuated this phenotypic shift in vitro, demonstrating involvement of JNK signaling in this process. Interestingly, activation of JNK signaling was also clearly present in lungs of SPC–TNF-α mice and patients with COPD. Together, these data show a role for TNF-α in the induction of a phenotypic shift in vitro, resulting in increased collagen production and the expression of elastin-degrading matrix metalloproteinases, and provide evidence for involvement of the TNF-α–JNK axis in extracellular matrix remodeling.

Objectives To examine associations between adiposity and adiposity change (loss, stable, gain) and subsequent longitudinal cognitive performance in African Americans in mid and late life. Design Cohort study using linear mixed models. Setting Genetic Epidemiology Network of Arteriopathy. Participants African‐American sibships with hypertension in Jackson, Mississippi (N = 1,108). Measurements Waist circumference and body mass index ( BMI ) were measured at two examinations 5 years apart. Stable adiposity was defined as values within 5% of the first measure. A composite cognitive Z ‐score was derived from individual cognitive test Z ‐scores at two study visits 6 years apart. Results Larger waist circumference was associated with greater rate of cognitive decline during follow‐up (beta = −0.0009 per year, P = .001); BMI , change in waist circumference, and change in BMI were not associated with rate of decline. Loss of adiposity in midlife was associated with higher cognitive Z ‐scores in middle‐aged individuals, and loss of adiposity in late life was associated with lower Z ‐scores in older adults ( P = .01 for interaction between waist circumference and age; P = .04 for interaction between BMI and age). Simultaneous inclusion of waist circumference and BMI in the cross‐sectional model suggested an association between larger waist circumference and poorer cognitive performance (beta = −0.009, P = .006) and between higher BMI and better cognitive performance (beta = 0.014, P = .06). Conclusion The results suggested a differential pattern of the relationship between adiposity and cognition according to age (mid‐ or late life) and regional distribution of adiposity.

Background: Despite the large increase in total hip arthroplasties and total knee arthroplasties, the incidence and prevalence of additional contralateral or ipsilateral joint arthroplasty are poorly understood. The purpose of this study was to determine the rate of additional joint arthroplasty after a primary total hip arthroplasty or total knee arthroplasty. Methods: This historical cohort study identified population-based cohorts of patients who underwent primary total hip arthroplasty (n = 1,933) or total knee arthroplasty (n = 2,139) between 1969 and 2008. Patients underwent passive follow-up through their medical records beginning with the primary total hip arthroplasty or total knee arthroplasty. We assessed the likelihood of undergoing a subsequent total joint arthroplasty, including simultaneous and staged bilateral procedures. Age, sex, and calendar year were evaluated as potential predictors of subsequent arthroplasty. Results: During a mean follow-up of 12 years after an initial total hip arthroplasty, we observed 422 contralateral total hip arthroplasties (29% at 20 years), 76 contralateral total knee arthroplasties (6% at 10 years), and 32 ipsilateral total knee arthroplasties (2% at 20 years). Younger age was a significant predictor of contralateral total hip arthroplasty (p < 0.0001), but not a predictor of the subsequent risk of total knee arthroplasty. During a mean follow-up of 11 years after an initial total knee arthroplasty, we observed 809 contralateral total knee arthroplasties (45% at 20 years), 31 contralateral total hip arthroplasties (3% at 20 years), and 29 ipsilateral total hip arthroplasties (2% at 20 years). Older age was a significant predictor of ipsilateral or contralateral total hip arthroplasty (p < 0.001). Conclusions: Patients undergoing total hip arthroplasty or total knee arthroplasty can be informed of a 30% to 45% chance of a surgical procedure in a contralateral cognate joint and about a 5% chance of a surgical procedure in noncognate joints within 20 years of initial arthroplasty. Increased risk of contralateral total knee arthroplasty following an initial total hip arthroplasty may be due to gait changes prior to and/or following total hip arthroplasty. The higher prevalence of bilateral total hip arthroplasty in younger patients may result from bilateral disease processes that selectively affect the young hip, such as osteonecrosis, or structural hip problems, such as acetabular dysplasia or femoroacetabular impingement. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

➢ Ulnar collateral ligament injuries are best classified according to chronicity of injury and grade of tear, with partial tears and nondisplaced tears being amenable to nonoperative treatment. ➢ In general, acute injuries may be primarily repaired with suture-anchor fixation, most often to the insertion of the ligament on the proximal phalanx, which allows for early joint range of motion. ➢ Symptomatic chronic injuries may be managed surgically with primary repair, reconstruction, or arthrodesis.

BACKGROUNDThere is a concerted push for adopting a minimalist strategy with emphasis on early hospital discharge for patients undergoing Transcatheter aortic valve implantation (TAVI). However, studies on discharge patterns and predictors of early discharge (≤3 days post‐TAVI) are sparse, in the United States.METHODSWe analyzed using Healthcare Utilization Project, Nationwide Inpatient Sample database, 2011‐2012. A total of 7321 TAVI procedures were identified. We compared in‐hospital outcomes between early and late discharge cohorts, and determined the predictors of early discharge. Correlation of costs and post‐TAVI length of stay was also performed.RESULTSEarly discharge rate post‐TAVI was about 21% in the United States, in 2011‐2012. Overall mean age was 81 years. In‐hospital adverse outcomes post‐TAVI were higher in late discharge cohort (P < 0.001). Mean length of stay post‐TAVI (7.7 days vs 2.6 days) and costs ($208 752 vs $157 663) were significantly higher in late discharge than early discharge cohort. Females, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support, acute kidney injury were associated with significantly lower adjusted odds for early discharge. Transfemoral TAVI approach, prior aortic valvuloplasty, and procedure year 2012 were associated with significantly higher odds for early discharge. We observed positive correlation between costs of hospitalization and post‐TAVI length of stay (R = 0.58; P < 0.001).CONCLUSIONSFemales, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support devices, renal failure were associated with lower odds for early discharge. Transfemoral approach and prior aortic valvuloplasty increased the likelihood for early discharge. Post‐TAVI length of stay was associated with significantly higher hospitalization costs.