Faculty Bibliography

OBJECTIVE:The objective of this pilot study was to assess physical therapists' (PTs) knowledge and needs regarding headache diagnosis and management. BACKGROUND:While there is significant research on physical therapy and cervicogenic headache, studies suggest that migraine is often under-recognized, misdiagnosed, and inadequately treated across society despite its high prevalence and burden. Because migraine commonly includes concurrent neck pain and/or vestibular symptoms, patients with migraine may present to PTs for treatment. Very little is known about PTs' headache and migraine education, knowledge, and clinical practices. METHODS:A team of headache specialists and PTs adapted a previously used headache knowledge and needs assessment survey to help ascertain PTs' knowledge and needs regarding headache treatment. The cross-sectional survey was distributed online via Research Electronic Data Capture (REDCap) to PTs within a large healthcare system in Connecticut. RESULTS:An estimated 50.5% (101/200) of PTs invited to complete the survey did so. Only 37.6% (38/101) of respondents reported receiving any formal headache or migraine education in their professional training, leading to knowledge gaps in differentiating and responding to headache subtypes. Only 45.5% (46/101) were able to identify that migraine is characterized by greater pain intensity than tension-type headache, and 22.8% (23/101) reported not knowing the duration of untreated migraine. When asked about the aspects of care they believe their patients with headache would like to see improved, PTs reported education around prevention and appropriate medication use (61/100 [61.0%]), provider awareness of the degree of disability associated with migraine (51/100 [51.0%]), and diagnostics (47/100 [47.0%]). CONCLUSION/CONCLUSIONS:This sample of PTs from one healthcare system demonstrates knowledge gaps and variations in clinical practice for managing their patients with headache. Future research on integrating additional opportunities for headache education for physical therapists, including evidence-based behavioral therapies, is needed to ascertain whether it is likely to improve patient care.

Multi-cancer early detection (MCED) tests are already being marketed as noninvasive, convenient opportunities to test for multiple cancer types with a single blood sample. The technology varies-involving detection of circulating tumor DNA, fragments of DNA, RNA, or proteins unique to each targeted cancer. The priorities and tradeoffs of reaching diagnostic resolution in the setting of possible false positives and negatives remain under active study. Given the well-established role of imaging in lesion detection and characterization for most cancers, radiologists have an essential role to play in selecting diagnostic pathways, determining the validity of test results, resolving false-positive MCED test results, and evaluating tradeoffs for clinical policy. Appropriate access to and use of imaging tests will also factor into clinical guidelines. Thus, all clinicians potentially involved with MCED tests for cancer screening will need to weigh the benefits and harms of MCED testing, including consideration of how the tests will be used alongside or in place of other screening options, how diagnostic confirmation tests should be selected, and what the implications are for policy and reimbursement decisions. Further, patients will need regular support to make informed decisions about screening using MCED tests in the context of their personal cancer risks, health-related values, and access to care.

BACKGROUND:In response to the heavy burden of untreated substance use disorders (SUD) in hospital patients, many health systems are implementing addiction consult services staffed by interprofessional teams that diagnose SUD, make recommendations for SUD care in the hospital, and link patients to post-discharge treatment. In 2018, the New York City public hospital system began rolling out the Consult for Addiction Treatment and Care in Hospitals (CATCH) program in six hospitals. CATCH teams are comprised of an addiction-trained medical provider, social worker or addiction counselor, and peer counselor. METHODS:The study conducted qualitative interviews with CATCH staff at all six participating hospitals as part of a pragmatic trial studying the effectiveness and implementation of CATCH. The Consolidated Framework for Implementation Research (CFIR) framework guided interviews conducted from 2018 to 2021 with 26 staff at the start of implementation and with 33 staff 9-12 months post-implementation. The study team created a codebook a priori and further refined it through additional coding of initial interviews. Codes were systematically analyzed using the CFIR. RESULTS:Barriers and facilitators spanned four CFIR domains: inner setting, outer setting, process, and individual characteristics. Barriers identified were primarily related to the outer and inner settings, including patient characteristics and limited resources (e.g. medical comorbidities, homelessness), insurance, CATCH team role confusion, and infrastructure deficits (e.g., availability of physical space). Additional barriers related to process (workload burden), and characteristics of individuals (stigma and lack of comfort treating SUD among medical teams). Facilitators were mostly related to the characteristics of individuals on the CATCH team (advantages and expertise of the CATCH peer counselor, CATCH team communication and cohesiveness) and inner setting (CATCH team relationships with hospital staff, hospital leadership buy-in and support, and infrastructure). Community networks (outer setting) and CATCH training resources (process) were also facilitators of program implementation. CONCLUSION/CONCLUSIONS:Addiction consult services have great potential for improving care for hospital patients with SUD, but as new programs in busy hospital settings they face barriers to implementation that could impact their effectiveness. Barriers may be particularly impactful for programs operating in safety-net hospitals, given limited resources within the health system and the multiple and complex needs of their patients. Understanding the strengths of these programs as well as the barriers to their implementation is critical to utilizing addiction consult services effectively.

OBJECTIVE:The goal is to provide an overview of artificial intelligence (AI) and machine learning (ML) methodology and appraisal tailored to clinicians and researchers in the headache field to facilitate interdisciplinary communications and research. BACKGROUND:The application of AI to the study of headache and other healthcare challenges is growing rapidly. It is critical that these findings be accurately interpreted by headache specialists, but this can be difficult for non-AI specialists. METHODS:This paper is a narrative review of the fundamentals required to understand ML/AI headache research. Using guidance from key leaders in the field of headache medicine and AI, important references were reviewed and cited to provide a comprehensive overview of the terminology, methodology, applications, pitfalls, and bias of AI. RESULTS:We review how AI models are created, common model types, methods for evaluation, and examples of their application to headache medicine. We also highlight potential pitfalls relevant when consuming AI research, and discuss ethical issues of bias, privacy and abuse generated by AI. Additionally, we highlight recent related research from across headache-related applications. CONCLUSION/CONCLUSIONS:Many promising current and future applications of ML and AI exist in the field of headache medicine. Understanding the fundamentals of AI will allow readers to understand and critically appraise AI-related research findings in their proper context. This paper will increase the reader's comfort in consuming AI/ML-based research and will prepare them to think critically about related research developments.

INTRODUCTION/BACKGROUND:The United States is facing an opioid use disorder (OUD) epidemic, marked by unprecedented overdose death rates. In New York State, synthetic opioids significantly contribute to the increasing overdose deaths, disproportionately impacting Black and Latinx communities. There is an urgent need to address issues related to equitable access to and the quality of care provided by substance use disorder (SUD) treatment programs. In light of this, the Quality Measurement and Management Research Center (QM2-RC) brought together an academic-government partnership to develop a person-centered quality measurement system and to assess its impact on a statewide treatment system that serves approximately 180,000 individuals per year. METHODS AND ANALYSIS/METHODS:The QM2-RC encompasses three interconnected projects (Project 1, 2, and 3) aimed at developing a quality management strategy and evaluating its impact on system performance across New York State. This report specifically focuses on Project 3, which involves a stepped-wedge trial with 35 clinics receiving a quality management intervention that includes performance coaching. This intervention will be compared to a treatment-as-usual (TAU) condition for clinics not participating in the trial. Administrative data will be utilized to monitor outcomes over four years. The coaching intervention, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) model, emphasizes interpreting quality measures and applying insights to enhance care. Coaches will provide support on data utilization, patient-centered care, harm reduction strategies, and the use of patient monitoring tools. The trial aims to evaluate clinic staff and leadership attitudes, experiences, and behaviors through surveys, semi-structured interviews, and external facilitator notes. Primary clinic outcomes will be assessed through adverse events, decreased clinic rates of substance use related emergency department visits and hospitalizations as well as mortality among patients within the first 12 months after admission to treatment after adjusting for individual and community level characteristics. This study is being developed over a multi-year period and will be informed by a mixed-methods approach incorporating multiple data sources, qualitative interviews, patient and clinic surveys. The study is being conducted in partnership with New York State Office of Addiction Services and Supports (OASAS) and will be informed by input from patient, providers, health insurers, family members and local governing units. DISCUSSION/CONCLUSIONS:Project 3 of the QM2 study specifically targets key barriers in measuring the quality of SUD treatment, including technological limitations, unvalidated measures, workforce data literacy, and concerns about fairness in assessing clinical complexity. Through the implementation of a stepped-wedge trial involving 35 clinics, the project aims to develop new quality measures, offer performance feedback, and engage clinic leadership and staff in efforts to improve practices. The ultimate goal of Project 3 is to overcome these barriers, promote person-centered care, and improve SUD treatment practices across New York State.

Repetitive head impacts are common in contact and collision sports and are linked to structural brain changes and an elevated risk of neurodegenerative diseases such as Chronic Traumatic Encephalopathy. Identifying early in vivo structural markers remains challenging. Although diagnosis currently requires post-mortem confirmation, clinical symptoms, including cognitive impairment and behavioural changes, are reflected in the diagnosis of Traumatic Encephalopathy Syndrome. These symptoms align with dysfunction in key brain regions-amygdala, hippocampus and thalamus-which support memory, emotion and behaviour and commonly show tau pathology in Chronic Traumatic Encephalopathy. This study uses shape analysis to examine structural differences in these regions between former American football players and unexposed asymptomatic controls and evaluates the influence of age, head impact exposure and clinical diagnosis on brain structure. We analyzed brain morphology in former American football players (n = 163) and unexposed, asymptomatic controls (n = 53). Structural segmentation was performed with FreeSurfer 7.1, and the shape analysis pipeline was used to generate subregional reconstructions. Vertex-level morphometry, based on the logarithm of the Jacobian determinant and radial distance, quantified local surface area dilation and thickness. Group differences were examined with covariate-adjusted linear regression models contrasting football players and controls, as well as participants with and without a Traumatic Encephalopathy Syndrome diagnosis. Partial correlations examined the influence of age, age of first football exposure and cumulative head impact index metrics, including frequency, linear acceleration and rotational force. Models were adjusted accordingly for age, body mass index, education, race, imaging site, apolipoprotein

Despite progress to define primary care practice transformation models, there remain gaps in translating evidence-based guidelines into routine clinical care. Primary care providers (MD, DO, NP, PA) and researchers need tools to assess modifiable factors that improve practice performance to inform practice transformation efforts. We aimed to develop a pragmatic tool for assessing practice-level primary care structures and processes that are associated with better care quality and clinical outcomes. We generated 314 candidate items for the Tool for Advancing Practice Performance (TAPP) using data from a comprehensive literature review, Delphi study, and qualitative interviews with high-performing practices. We used empirical criteria and expert review to eliminate redundancy and improve clarity via removing and retaining items. The retained items were formatted into a survey tool, and we further revised the tool based on feedback elicited from cognitive interviews and pilot testing with primary care providers and staff. The final candidate pool comprised 126 items after refinement and expert review. For the survey tool, we adapted and developed survey questions for each of the 126 items. Eight cognitive interview participants reviewed the tool and provided feedback on its content and language. Based on this feedback, we eliminated 13 items because they were poorly or incorrectly understood by participants, resulting in a 113-item tool. Fifteen participants pilot tested the tool and no additional items were eliminated. The TAPP is a novel, low-burden tool that researchers and primary care providers can use to identify areas for improvement at the practice-level. Practices and health systems could use the TAPP to assess their own performance and identify gaps in their structures and processes, and practice networks and health systems can use the tool to assess structures and processes at individual clinics, track this information over time, and evaluate its relationship to care quality and clinical outcomes.

UNLABELLED: HIGHLIGHTS/UNASSIGNED:A new oral cancer simulation model with risk factors including degrees of smoking and alcohol exposure, oral lesion features, and sex incorporates more accurate and precise representation of patient risk categories.We evaluated screening strategies for oral potentially malignant disorders with or without risk-stratified biopsy referral in both the general population and subpopulations defined by degrees of smoking and alcohol exposure.Men with a high degree of both smoking and alcohol exposure exhibited a significant reduction in cancer-specific deaths and cancer incidence from screening programs for oral potentially malignant disorders.Screening with risk-stratified biopsy, using a surgical treatment threshold of moderate dysplasia or worse, yielded the greatest efficiency in term of biopsies needed to detect 1 treatable case.