Structures of the promoter-bound respiratory syncytial virus polymerase.

The respiratory syncytial virus (RSV) polymerase is a multifunctional RNA-dependent RNA polymerase composed of the large (L) protein and the phosphoprotein (P). It transcribes the RNA genome into ten viral mRNAs and replicates full-length viral genomic and antigenomic RNAs1. The RSV polymerase initiates RNA synthesis by binding to the conserved 3'-terminal RNA promoters of the genome or antigenome2. However, the lack of a structure of the RSV polymerase bound to the RNA promoter has impeded the mechanistic understanding of RSV RNA synthesis. Here we report cryogenic electron microscopy structures of the RSV polymerase bound to its genomic and antigenomic viral RNA promoters, representing two of the first structures of an RNA-dependent RNA polymerase in complex with its RNA promoters in non-segmented negative-sense RNA viruses. The overall structures of the promoter-bound RSV polymerases are similar to that of the unbound (apo) polymerase. Our structures illustrate the interactions between the RSV polymerase and the RNA promoters and provide the structural basis for the initiation of RNA synthesis at positions 1 and 3 of the RSV promoters. These structures offer a deeper understanding of the pre-initiation state of the RSV polymerase and could aid in antiviral research against RSV.

The role of iliopsoas fractional lengthening in hip arthroscopy: a systematic review.

Arthroscopic iliopsoas fractional lengthening (IFL) is a surgical option for the treatment of internal snapping hip syndrome (ISHS) after failing conservative management. Systematic review. A search of PubMed central, National Library of Medicine (MEDLINE) and Scopus databases were performed by two individuals from the date of inception to April 2023. Inclusion criteria were ISHS treated with arthroscopy. Sample size, patient-reported outcomes and complications were recorded for 24 selected papers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and registered on PROSPERO database for systematic reviews (CRD42023427466). Thirteen retrospective case series, ten retrospective comparative studies, and one randomized control trial from 2005 to 2022 were reported on 1021 patients who received an iliopsoas fractional lengthening. The extracted data included patient satisfaction, visual analogue scale, the modified Harris hip score and additional outcome measures. All 24 papers reported statistically significant improvements in post-operative patient-reported outcome measures after primary hip arthroscopy and iliopsoas fractional lengthening. However, none of the comparative studies found a statistical benefit in performing IFL. Existing studies lack conclusive evidence on the benefits of Iliopsoas Fractional Lengthening (IFL), especially for competitive athletes, individuals with Femoroacetabular Impingement (FAI), and borderline hip dysplasia. Some research suggests IFL may be a safe addition to hip arthroscopy for Internal Snapping Hip Syndrome, but more comprehensive investigations are needed. Future studies should distinguish between concurrent procedures and develop methods to determine if the psoas muscle is the source of pain, instead of solely attributing it to the joint.

Gracilis Free Flap in a Patient with Sickle Cell Disease.

Introduction: Free tissue transfer in the sickle cell population presents many challenges to the reconstructive surgeon. There are few reported cases of successful free tissue transfers within the sickle cell population. The majority of successful cases involve fasciocutaneous free flaps with few successful muscle flaps. This case report describes the successful utilization of a gracillis free flap to reconstruct a multifocal soft tissue defect following a closed distal tibia fracture in a patient with sickle cell disease (SCD). Case Report: This is a 20-year-old female with past medical history significant for sickle cell anemia, cardiomyopathy secondary to a ventricular septal defect and multiple occurrences of osteomyelitis who underwent gracilis free flap transfer to reconstruct soft tissue loss around the ankle after surgical fixation of a left pathological tibia fracture. Conclusion: The use of free flaps in sickle cell patients has shown to be extremely challenging due to the high risks of sickling and subsequent pedicle thrombosis associated with this population. However, there have been an increasing number of successful cases of free tissue transfers with most of these flaps arising from muscular origins. Therefore, more cases regarding free flaps in the sickle cell population are needed to fully understand the best protocols to follow. The techniques utilized among successful cases, regarding protocols prior to the surgery along with successful graft location selection, can help advance future cases and shows promise for future sickle cell patients.

Hybrid Single-Port Cholecystectomy of a Pediatric Gallbladder Volvulus.

Gallbladder volvulus is a rare gallbladder pathology that can present in adults but is exceedingly rare in children. The diagnosis itself can be very challenging due to its presentation with signs and symptoms of acute cholecystitis without specific imaging findings. The correct identification and prompt intervention with a cholecystectomy are crucial to improve patient outcomes. In this report, we discuss a pediatric patient who presented with gallbladder volvulus and subsequently underwent novel treatment with a single-port laparoscopic cholecystectomy. The patient is a 12-year-old male of Haitian descent who presented to an outside facility following the onset of persistent, right upper quadrant abdominal pain and recurrent nonbilious emesis. The diagnostic workup included serial abdominal exams, laboratory work, right upper quadrant ultrasounds, and a hepatobiliary iminodiacetic acid (HIDA) scan. The patient then underwent single-port laparoscopic removal of the torsed gallbladder with complete resolution of his symptoms. In this case report, the management and clinical presentation of gallbladder volvulus are discussed in more detail as well as the feasibility of single-port laparoscopic cholecystectomy in the setting of pediatric gallbladder volvulus.

Staffing in a Level 1 Trauma Center: Quantifying Capacity for Preparedness.

OBJECTIVE: We sought to determine who is involved in the care of a trauma patient. METHODS: We recorded hospital personnel involved in 24 adult Priority 1 trauma patient admissions for 12 h or until patient demise. Hospital personnel were delineated by professional background and role. RESULTS: We cataloged 19 males and 5 females with a median age of 50-y-old (interquartile range [IQR], 35.5-67.5). The average number of hospital personnel involved was 79.71 (standard deviation, 17.62; standard error 3.6). A median of 51.2% (IQR, 43.4%-59.8%) of personnel were first involved within hour 1. More personnel were involved in direct versus indirect care (median 54.5 [IQR, 47.5-67.0] vs 25.0 [IQR, 22.0-30.5]; P < 0.0001). Median number of health-care professionals and auxiliary staff were 74.5 (IQR, 63.5-90.5) and 6.0 (IQR, 5.0-7.0), respectively. More personnel were first involved in hospital locations external to the emergency department (median, 53.0 [IQR, 41.5-63.0] vs 27.5 [IQR, 24.0-30.0]; P < 0.0001). No differences existed in total personnel by Injury Severity Score (P = 0.1266), day (P = 0.7270), or time of admission (P = 0.2098). CONCLUSIONS: A large number of hospital personnel with varying job responsibilities respond to severe trauma. These data may guide hospital staffing and disaster preparedness policies.

Postdischarge Opioid Use after Total Hip and Total Knee Arthroplasty.

BACKGROUND: As America's third highest opioid prescribers, orthopedic surgeons have contributed to the opioid abuse crisis. This study evaluated opioid use after primary total joint replacement. We hypothesized that patients who underwent total hip arthroplasty (THA) use fewer opioids than patients who underwent total knee arthroplasty (TKA) and that both groups use fewer opioids than prescribed. METHODS: A prospective study of 110 patients undergoing primary THA or TKA by surgeons at an academic center during 2018 was performed. All were prescribed oxycodone 5 mg, 84 tablets, without refills. Demographics, medical history, and operative details were collected. Pain medication consumption and patient-reported outcomes were collected at 2 and 6 weeks postoperatively. Analysis of variance was performed on patient and surgical variables. RESULTS: Sixty-one patients scheduled for THA and 49 for TKA were included. THA patients consumed significantly fewer opioids than TKA patients at 2 weeks (28.1 tablets vs 48.4, P = .0003) and 6 weeks (33.1 vs 59.3, P = .0004). Linear regression showed opioid use decreased with age at both time points (P = .0002). A preoperative mental health disorder was associated with higher usage at 2 weeks (58.3 vs 31.4, P < .0001) and 6 weeks (64.7 vs 39.2, P = .006). Higher consumption at 2 weeks was correlated with worse outcome scores at all time points. CONCLUSIONS: TKA patients required more pain medication than THA patients, and both groups received more opioids than necessary. In addition, younger patients and those with a preexisting mental health disorder required more pain medication. These data provide guidance on prescribing pain medication to help limit excess opioid distribution.