Citations

Background: Adequate cam resection during hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is necessary to restore femoral head-neck offset while avoiding under- or over-resection. The relationship between the extent of femoroplasty and postoperative patient-reported outcomes remains unclear. Purpose: We sought to answer the following questions: What is the association between the extent of cam femoroplasty resection and postoperative improvements? and is a 5% resection threshold associated with improved outcomes? Methods: We conducted a retrospective review of patients with adequate acetabular coverage who underwent primary hip arthroscopy with femoroplasty between January 2015 and December 2022 at our institution and had preoperative and 1- and/or 2-year postoperative modified Harris hip score (mHHS) and/or International Hip Outcome Tool (iHOT) scores. We included 400 patients (409 hips; ages 14–50 years). Outcomes included score changes and achievement of minimum clinically important difference (MCID) and substantial clinical benefit (SCB). Postoperative Dunn lateral radiographs quantified femoroplasty by resection depth percentage (resection depth/femoral head diameter), proximal resection angle, and postoperative α angle. Hips were classified as under-resection, neutral (0%–5%), or over-resection (>5%), and differences in outcomes were compared between resection groups. Multivariable regression analyses controlled for demographic, radiographic, and surgical variables. Results: Mean resection depth was 4.8%; mean proximal resection angle was 72.6°. No differences were observed in score improvements or MCID/SCB rates between groups with under-resection versus over-resection at 1 or 2 years. Greater resection depth was associated with larger 1-year mHHS and iHOT improvements and independently predicted 1-year iHOT MCID and SCB. Higher proximal resection angle predicted 2-year iHOT MCID. Conclusion: In this retrospective, single-institution cohort study, we found that in patients with FAIS, greater femoroplasty depth was associated with improved 1-year clinical outcomes. Level of Evidence: Level III, retrospective cohort study.

Abstract Creating a People-Centered Organization: 12 Organizational Actions to Reduce Burnout and Foster Professional Fulfillment tells the story of the evolving journey to create a better work environment for health care professionals. It dwells not on the story of occupational distress, burnout, moral injury, and cognitive dissonance but rather on a narrative of hope, well-being, camaraderie, values alignment, and meaning. Achieving this aspiration requires health care professionals and operational leaders working together to create 10 “Ideal Work Elements”: community at work and camaraderie; intrinsic motivation and rewards; control and flexibility; fairness and equity; professional development and mentorship; partnership; safety; trust and respect; gratitude; and work–life Integration. The ultimate aspiration is a people-centered organization with a culture that inspires enthusiasm, loyalty, engagement, and strong regard for the welfare of the team and the best interests of patients. Creating a People-Centered Organization: 12 Organizational Actions to Reduce Burnout and Foster Professional Fulfillment provides a road map for you to create such an environment for your team and organization. The map is paved with information about reliable, thoughtfully designed systems built on a psychologically safe and just culture. The authors drew on their extensive research on the well-being of health care professionals and their executive leadership experience in staff wellness, quality improvement, organization development, and operations management.

Abstract As health care organizations in the United States move toward recovery from the COVID-19 pandemic, physicians and clinical faculty are experiencing occupational burnout and various manifestations of distress. To mitigate these challenges, health care organizations must optimize the work environment and provide support for individual clinicians using a variety of approaches, including mentoring, group-based peer support, individual peer support, coaching, and psychotherapy. While often conflated, each of these approaches offers distinct benefits. Mentoring is a longitudinal 1-on-1 relationship, typically focused on career development, usually with an experienced professional guiding a junior professional. Group-based peer support involves regular, longitudinal meetings of health professionals to discuss meaningful topics, provide mutual support to one another, and foster community. Individual peer support involves training peers to provide timely 1-on-1 support for a distressed colleague dealing with adverse clinical events or other professional challenges. Coaching involves a certified professional helping an individual identify their values and priorities and consider changes that would allow them to adhere to these more fully, and providing longitudinal support that fosters accountability for action. Individual psychotherapy is a longitudinal, short- or long-term professional relationship during which specific therapeutic interventions are delivered by a licensed mental health professional. When distress is severe, this is the best approach. Although some overlap exists, these approaches are distinct and complementary. Individuals may use different methods at different career stages and for different challenges. Organizations seeking to address a specific need should consider which approach is most suitable. Over time, a portfolio of offerings is typically needed to holistically address the diverse needs of clinicians. A stepped care model using a population health approach may be a cost-effective way to promote mental health and prevent occupational distress and general psychiatric symptoms.

The majority of quality measures used to assess providers and hospitals are based on easily obtained data, focused on a few dimensions of quality, and developed mainly for primary/community care and population health. While this approach supports efforts focused on addressing the triple aim of health care, many current quality report cards and assessments do not reflect the breadth or complexity of many referral center practices. In this article, the authors highlight the differences between population health efforts and referral care and address issues related to value measurement and performance assessment. They discuss why measures may need to differ across the three levels of care (primary/community care, secondary care, complex care) and illustrate the need for further risk adjustment to eliminate referral bias. With continued movement toward value-based purchasing, performance measures and reimbursement schemes need to reflect the increased level of intensity required to provide complex care. The authors propose a framework to operationalize value measurement and payment for specialty care, and they make specific recommendations to improve performance measurement for complex patients. Implementing such a framework to differentiate performance measures by level of care involves coordinated efforts to change both policy and operational platforms. An essential component of this framework is a new model that defines the characteristics of patients who require complex care and standardizes metrics that incorporate those definitions.

572 Background: Renal medullary carcinoma (RMC) is an aggressive malignancy affecting predominantly young African Americans with sickle cell trait (SCT) or disease (SCD), while a pathologically similar collecting duct carcinoma (CDC) affects patients without sickle cell trait. Clinical responses to chemotherapy and IL-2 in RMC/CDC are poor and novel therapies are needed. Methods: 9 patients with RMC (ages 13-58 y. o., all male) and 15 patients (ages 26-74 y. o., M:F = 13:2) with collecting duct carcinoma (CDC) were studied. Expression of PD-L1 was evaluated with 2 monoclonal antibodies (SP142 and SP263) and tumor infiltrating lymphocytes (TIL) were evaluated for PD1 expression (MRQ-22 antibody) using immunohistochemistry (IHC). Additional studies included ALK protein expression (D5F3 antibody), gene translocation (break apart FISH), next generation sequencing (NGS), and microsatellite instability (MSI). Results: Cancer cell PD-L1 expression above the threshold ( ≥ 2+, ≥ 5%) was seen in 7/9 RMC and 5/13 CDC cases. Concordance between 2 PD-L1 antibodies was 94.4%. PD-1+ TIL were absent in 6/18 cases and variably present in 12/18 cases (from 1 to > 15 TIL/40x power field). No MSI was detected in any of the cases tested (0/6). No case expressed ALK protein, but one case of CDC showed ALK gene re-arrangement. Mutations were identified in SMARCB1, FH, TP53 (3x), ATM, BRCA2, CHEK2 (2x), NF2 (3x), SETD2, and CDKN2A. No mutations in VHL or KDR were detected. One patient with RMC (and SCT) achieved complete clinical remission after treatment with bevacizumab plus paclitaxel. Conclusions: RMC and CDC strongly express PD-L1 in the majority of cases (12/22), suggesting that these patients may benefit from targeting the PD-L1/PD1 interaction. The absence of MSI in these cancers indicates a different mechanism of PD-L1 upregulation from colorectal carcinomas. Consistent with our previous study that showed frequent activation of (pseudo)hypoxia-induced pathways in RMCs (Human Pathology 2011;42:1979), we describe a case of RMC successfully treated with anti-VEGF therapy.

Abstract Studies suggest that screening with spiral computed tomography can detect lung cancers at a smaller size and earlier stage than chest radiography can. To evaluate low-radiation-dose spiral computed tomography and sputum cytology in screening for lung cancer, we enrolled 1,520 individuals aged 50 yr or older who had smoked 20 pack-years or more in a prospective cohort study. One year after baseline scanning, 2,244 uncalcified lung nodules were identified in 1,000 participants (66%). Twenty-five cases of lung cancer were diagnosed (22 prevalence, 3 incidence). Computed tomography alone detected 23 cases; sputum cytology alone detected 2 cases. Cell types were: squamous cell, 6; adenocarcinoma or bronchioalveolar, 15; large cell, 1; small cell, 3. Twenty-two patients underwent curative surgical resection. Seven benign nodules were resected. The mean size of the non-small cell cancers detected by computed tomography was 17 mm (median, 13 mm). The postsurgical stage was IA, 13; IB, 1; IIA, 5; IIB, 1; IIIA, 2; limited, 3. Twelve (57%) of the 21 non-small cell cancers detected by computed tomography were stage IA at diagnosis. Computed tomography can detect early-stage lung cancers. The rate of benign nodule detection is high.