Beyond medical knowledge: a didactic curriculum focused on knowledge, wisdom, and application.

OBJECTIVE: The aim of this study was to determine whether a flipped classroom curriculum coupled with case-based learning would improve residents' perceptions of the learning environment, improve education outcomes, and increase faculty engagement. Research suggests that active learning yields better educational results compared with passive learning. However, faculty are more comfortable providing lectures that require only passive participation from learners. METHODS: A council was created to identify issues with the current format of the resident didactic curriculum and to redesign the neurosurgical curriculum and conference per Accreditation Council for Graduate Medical Education (ACGME) requirements. Trends from the authors' 2022 and 2023 ACGME Resident Surveys were tracked to assess changes in the organizational learning environment. Surveys of resident participants were conducted to assess learner satisfaction. RESULTS: Between July 2022 and June 2023, the authors gathered 127 survey responses from neurosurgical residents. The majority of respondents, comprising 50.4% (n = 64), were postgraduate year (PGY)-4 and PGY-5 residents. Sixty-six percent (n = 84) reported that the new format ranked within the top third of sessions they had experienced. On analysis of trends from these 2022 and 2023 ACGME Resident Surveys, the authors observed a positive trajectory in various key components. Notably, there was an upward trend in achieving an appropriate balance between service and education, in the availability of protected time for structured learning, faculty engagement and interest in education, and amount of clinical and didactic teaching. CONCLUSIONS: The results of this study suggest that this innovative educational model can have a positive impact on residents' perceptions of the learning environment, their educational outcomes, and faculty engagement. As residency education continues to evolve, the flipped classroom model offers an exciting avenue for enhancing the quality of residency education.

Longitudinal associations between exclusive, dual and polytobacco use and respiratory illness among youth.

Background: The health consequences of polytobacco use are still well not understand. We evaluated prospective associations between exclusive, dual, and polytobacco use and diagnosed bronchitis, pneumonia, or chronic cough among US youth. Methods: Data came from Waves 1-5 of the Population Assessment of Tobacco and Health Study. We categorized time-varying past 30-day tobacco use into seven categories: (1) non-current use; exclusive use of 2) cigarettes, 3) electronic nicotine delivery systems (ENDS), or 4) other combustible products (OC; pipes, hookah, and cigars); dual use of 5) ENDS + cigarettes or ENDS + OC 6) cigarettes + OC; or 7) polyuse of all three products. The outcome was incident diagnosis of bronchitis, pneumonia, or chronic cough. We conducted weighted multilevel Poisson models (person n = 17,517, 43,290 observations) to examine the longitudinal exposure-outcome relationship, adjusting for covariates: sex, age, race and ethnicity, parental education, body mass index, secondhand smoke exposure, and household use of combustible products. Results: Compared to nonuse, exclusive cigarette use (Incidence Rate Ratio (IRR) = 1.83, 95% CI 1.25-2.68), exclusive ENDS use (IRR = 1.53, 95% CI 1.08-2.15), combustible product + ENDS dual use (IRR = 1.90, 95% CI 1.18-3.04), cigarettes + OC dual use (IRR = 1.96, 95% CI 1.11-3.48), and polytobacco use (IRR = 3.06 95% CI 1.67-5.63) were associated with a higher incidence of bronchitis, pneumonia, or chronic cough. Conclusion: We found that exclusive, dual, and poly tobacco use was associated with higher incidence of bronchitis, pneumonia, or chronic cough; Moreover, the incidence rate ratio for polytobacco use was higher than the incidence rate ratio for exclusive use compared to non-current use.

Prevalence and distribution of Varroa destructor and Nosema spp. in symptomatic honey bee colonies across the USA from 2015 to 2022.

USDA-ARS Bee Research Laboratory received symptomatic honey bee (Apis mellifera L.) samples across the United States for disease diagnosis. Here, we present a retrospective study and cartography of ectoparasite Varroa destructor and intracellular microsporidia parasite Nosema spp. These two major parasites were identified in the diseased honey bee samples between 2015 and 2022. Varroa infestation level (VIL) was examined by a wash technique (Mites/100 bees) and calculated as a percentage, while Nosema infection was quantified by microscopical spore count (Million Spores/Bee). Data were analyzed by month, year, state, and by nine geographical climate regions described in the U.S. Of adult bee samples (n = 4039) that were analyzed for Varroa mite infestation, the overall VIL in the U.S. ranged between 0.4 and 30.85%, with an overall national VIL and Varroa prevalence of 8.21% and 85.14%, respectively. Overall monthly data showed VIL constantly exceeded the critical level of 4% except from June to September and reached a maximum of 15% in January and December. Nationwide, VIL significantly (p < 0.001) increased from 2015 to 2018 (1.1-4.7%), plateaued from 2018 to 2021 (4.7-4.5%), followed by a significant decrease in 2022 (3.6%). Significant VIL differences (p < 0.001) were recorded among climate regions, with the highest mite infestation levels in the Upper Midwest region (13.9%) and the lowest in the West region (5.1%). Of adult bee samples (n = 2,994) that were analyzed for Nosema infection, Nosema spore count ranged between (1-16.8) million spores per bee among states, with a national average of 6.8 and a prevalence of 99.7%. The lowest and highest Nosema loads were respectively recorded in the South region (3.1) and Upper Midwest (10.5), a significant difference (p < 0.001). No statistical differences were recorded among the six other climate regions. Overall, VIL and Nosema infection correlated significantly (p < 0.001) with a regression coefficient of (R2 = 0.6). Our data, which originated from ailing bee colonies, showed significantly higher rates of maladies compared to data from healthy colonies obtained by the USDA-APHIS National Honey Bee Survey, demonstrating the role of bee diseases caused by Varroa mite and Nosema in honey bee population declines.

Association between cigar use, with and without cigarettes, and incident diagnosed COPD: a longitudinal cohort study.

BACKGROUND: While regular cigar smoking is believed to carry similar health risks as regular cigarette smoking, the impact of cigar use, alone or in combination with cigarettes, on obstructive pulmonary disease (COPD) has not been well characterized. The purpose of this study was to examine the prospective association between exclusive and dual cigar and cigarette use and incident self-reported diagnosed COPD. METHODS: This study used data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative survey of U.S. adults. Longitudinal data from adults aged 40 to 79 at Wave 1, without a pre-existing COPD diagnosis who participated at follow-up interview were analyzed. A time-varying current tobacco exposure, lagged by one wave and categorized as: (a) never/non-current use; (b) exclusive cigar use; (c) exclusive cigarette use; and (d) dual cigar/cigarette use. Multivariable models adjusted for demographics (age, sex, race or ethnicity, education), clinical risk factors (asthma, obesity), and smoking-related confounders (second-hand smoke exposure, other combustible tobacco product use, e-cigarette use, time since quitting, cigarette pack-years). The incidence of self-reported diagnosed COPD was estimated using discrete-time survival models, using a general linear modeling (GLM) approach with a binomial distribution and a complementary log-log link function. RESULTS: The analytic sample consisted of 9,556 adults with a mean (SD) age of 56 (10.4), who were predominately female (52.8%) and Non-Hispanic White (70.8%). A total of 906 respondents reported a diagnosis of COPD at follow-up. In the fully adjusted model, exclusive cigar use (adjusted hazard ratio (aHR) = 1.57, 95% CI: 0.77, 3.21) was not associated with increased COPD risk compared to non-use, while exclusive cigarette use (aHR = 1.48, 95% CI: 1.13, 1.93) and dual cigar/cigarette use (aHR = 1.88, 95% CI: 1.24, 2.85) were. CONCLUSIONS: Exclusive cigarette use and dual cigar/cigarette use were associated with diagnosed incident COPD. These results suggest that cigars, when used in combination with cigarettes, may be associated with poorer COPD health outcomes. Dual use may promote a higher likelihood of inhaling cigar smoke, and future research would benefit from examining whether inhalation of cigar smoke increases COPD risk.

Prompt access to outpatient care post-incarceration among adults with a history of substance use: Predisposing, enabling, and need-based factors.

INTRODUCTION: As expanded Medicaid coverage reduces financial barriers to receiving health care among formerly incarcerated adults, more information is needed to understand the factors that predict prompt use of health care after release among insured adults with a history of substance use. This study's aim was to estimate the associations between characteristics suggested by the Andersen behavioral model of health service use and measures of health care use during the immediate reentry period and in the presence of Medicaid coverage. METHODS: In this retrospective cohort study, we linked individual-level data from multiple Wisconsin agencies. The sample included individuals aged 18-64 released from a Wisconsin State Correctional Facility between April 2014 and June 2017 to a community in the state who enrolled in Medicaid within one month of release and had a history of substance use. We grouped predictors of outpatient care into variable domains within the Andersen model: predisposing- individual socio-demographic characteristics; enabling characteristics including area-level socio-economic resources, area-level health care supply, and characteristics of the incarceration and release; and need-based- pre-release health conditions. We used a model selection algorithm to select a subset of variable domains and estimated the association between the variables in these domains and two outcomes: any outpatient visit within 30 days of release from a state correctional facility, and receipt of medication for opioid use disorder within 30 days of release. RESULTS: The size and sign of many of the estimated associations differed for our two outcomes. Race was associated with both outcomes, Black individuals being 12.1 p.p. (95 % CI, 8.7-15.4, P < .001) less likely than White individuals to have an outpatient visit within 30 days of release and 1.3 p.p. (95 % CI, 0.48-2.1, P = .002) less likely to receive MOUD within 30 days of release. Chronic pre-release health conditions were positively associated with the likelihood of post-release health care use. CONCLUSIONS: Conditional on health insurance coverage, meaningful differences in post-incarceration outpatient care use still exist across adults leaving prison with a history of substance use. These findings can help guide the development of care transition interventions including the prioritization of subgroups that may warrant particular attention.

ENDS, Cigarettes, and Respiratory Illness: Longitudinal Associations Among U.S. Youth.

INTRODUCTION: ENDS use is highly prevalent among U.S. youth, and there is concern about its respiratory health effects. However, evidence from nationally representative longitudinal data is limited. METHODS: Using youth (aged 12-17 years) data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, multilevel Poisson regression models were estimated to examine the association between ENDS use; cigarettes; and diagnosed bronchitis, pneumonia, or chronic cough. Current product use was lagged by 1 wave and categorized as (1) never/noncurrent use, (2) exclusive cigarette use, (3) exclusive ENDS use, and (4) dual ENDS/cigarette use. Multivariable models adjusted for age, sex, race and ethnicity; parental education; asthma; BMI; cannabis use; secondhand smoke exposure; and household use of combustible products. Data analysis was conducted in 2022-2023. RESULTS: A total of 7.4% of respondents were diagnosed with bronchitis, pneumonia, or chronic cough at follow-up. In the multivariable model, exclusive cigarette use (incident rate ratio=1.85, 95% CI=1.29, 2.65), exclusive ENDS use (incident rate ratio=1.49, 95% CI=1.06, 2.08), and dual use (incident rate ratio=2.70, 95% CI=1.61, 3.50) were associated with a higher risk of diagnosed bronchitis, pneumonia, or chronic cough than never/noncurrent use. CONCLUSIONS: These results suggest that ENDS and cigarettes, used exclusively or jointly, increased the risk of diagnosed bronchitis, pneumonia, or chronic cough among U.S. youth. However, dual use was associated with the highest risk. Targeted policies aimed at continuing to reduce cigarette smoking and ENDS use among youth, especially among those with dual use, are needed.

A longitudinal analysis of flavored cigar use and cigar smoking cessation among US adults.

BACKGROUND: Flavorings in cigars increase their appeal, mask the harsh taste of tobacco, and may hinder successful cigar smoking cessation; however, limited evidence has examined whether flavors are associated with short- or long-term cigar smoking cessation. METHODS: Using restricted data from the Population Assessment of Tobacco and Health Study Waves 1-5, we examined whether flavored cigar use was associated with 30-day-plus and 1-year-plus cigar smoking cessation among US adults. Multivariable discrete-time survival models were fit to a nationally representative sample of US adult (18+) respondents who had a current, established cigar use, smoked five or more days in the past 30 days, and did not exclusively smoke traditional premium cigars at baseline. Models adjusted for age, sex, race and ethnicity, income, cigar and cigarette smoking intensity, and blunt use. RESULTS: At baseline, 44.6% of respondents (n = 674) were 18-34 years old, 75.0% were male, 56.7% were non-Hispanic White, 78.9% had household incomes of <$50,000, and 56.2% smoked flavored cigars. In fully adjusted models, flavored cigar use was associated with a lower risk of 30-day-plus (HR = 0.76, 95% CI = 0.60, 0.97) but not 1-year-plus cigar smoking cessation (HR = 0.81, 95% = 0.62, 1.05). CONCLUSIONS: We found that flavored cigar use was associated with a lower risk of short-term but not long-term cigar smoking cessation. More work is needed to understand the dynamics of cigar smoking transitions, including initiation, cessation, and relapse, particularly in larger cohorts and among those who exclusively use cigars or dual-use cigars and cigarettes. IMPLICATIONS: As local and some state jurisdictions continue to adopt partial or complete bans of flavored cigar products and the United States Food and Drug Administration considers a national ban of all characterizing flavors in cigars, there is a need for more longitudinal work examining the associations between flavorings in cigars and short and long-term cigar smoking behaviors, including but not limited to initiation, cessation, intensity of use, and relapse, particularly in diverse cohorts.

Anatomical restructuring of a lateralized neural circuit during associative learning by asymmetric insulin signaling.

Studies of neuronal connectivity in model organisms, i.e., of their connectomes, have been instrumental in dissecting the structure-function relationship of nervous systems. However, the limited sample size of these studies has impeded analyses into how variation of connectivity across populations may influence circuit architecture and behavior. Moreover, little is known about how experiences induce changes in circuit architecture. Here, we show that an asymmetric salt-sensing circuit in the nematode Caenorhabditis elegans exhibits variation that predicts the animals' salt preferences and undergoes restructuring during salt associative learning. Naive worms memorize and prefer the salt concentration they experience in the presence of food through a left-biased neural network architecture. However, animals conditioned at elevated salt concentrations change this left-biased network to a right-biased network. This change in circuit architecture occurs through the addition of new synapses in response to asymmetric, paracrine insulin signaling. Therefore, experience-dependent changes in an animal's neural connectome are induced by insulin signaling and are fundamental to learning and behavior.

Trends of Single, Dual, and Polytobacco Use Among School-Based Students in the United States: An Analysis of the National Youth Tobacco Survey.

PURPOSE: To examine trends in single, dual, and polytobacco use between 2014-2020 for US youth and to identify disparities in these trends by grade level, sex, and race/ethnicity. DESIGN: A secondary analysis of the National Youth Tobacco Survey (NYTS). SUBJECTS: A total of 122 566 students. MEASURES: Past 30-day exclusive use of cigarettes, e-cigarettes, other combustibles (cigars, little cigars, cigarillos, hookah, pipe tobacco, bidis) and smokeless tobacco (snus, smokeless, dissolvable); dual use of each product with e-cigarettes; polyuse with e-cigarettes; dual/polyuse without e-cigarettes. ANALYSIS: Multivariable modified Poisson regression. RESULTS: Compared to 2014, exclusive e-cigarette use (APR = 2.51, 95% CI: 1.96, 3.21) trended upward while exclusive cigarette (APR = .34, 95% CI: .23, .50), 'other' combustibles (APR = .47, 95% CI: .37, .58), and smokeless tobacco (APR = .40, 95% CI: .25, .65) use trended downward in 2020. Polytobacco use with and without e-cigarettes trended downward in 2020 compared to 2014. We also saw differences in trends across sociodemographic groups. Comparing 2020 to 2014, exclusive e-cigarette use was higher for females than males, 'other' combustible tobacco use remained stable for Non-Hispanic Black students but decreased for other racial/ethnic groups, and dual e-cigarette/cigarette use trended upward more for middle school students than high school students. CONCLUSIONS: Despite decreased trends in tobacco product use without e-cigarettes between 2014-2020, differences in tobacco product use trends by grade level, sex, and race/ethnicity were identified. Prevention efforts targeting disparities in tobacco product use are needed.

The longitudinal association between coupon receipt and established cigarette smoking initiation among young adults in USA.

INTRODUCTION: Tobacco companies frequently distribute coupons for their products. This marketing tactic may be particularly effective among young adults, who tend to be especially price-sensitive. Young adulthood is also a stage during which many individuals initiate established cigarette smoking and are especially vulnerable to the effects of tobacco marketing. METHODS: We used five waves of data from the US Population Assessment on Tobacco and Health Study (2013-2019) to assess the longitudinal relationship between cigarette coupon receipt and initiation of established cigarette smoking among young adults (18-24 years) who did not report current smoking and had smoked <100 cigarettes in their lifetime at baseline. Initiation of established cigarette smoking was defined as reporting current cigarette use and having smoked ≥100 cigarettes at follow-up. To test this relationship, we fit four discrete time survival models to an unbalanced person-period data set. The first model included our time-varying coupon receipt variable, which was lagged one wave. Subsequent models added sociodemographic, cigarette smoking exposure and other tobacco use variables. RESULTS: Adopting the model adjusting for sociodemographic variables, respondents who received a coupon were found to be more likely to initiate established cigarette smoking at follow-up (adjusted HR (aHR): 2.31, 95% CI 1.41 to 3.80). This relationship remained significant when controlling for all covariates in the fully adjusted model (aHR: 1.96, 95% CI 1.18 to 3.26). CONCLUSIONS: These findings show that receiving tobacco coupons may increase the likelihood that young adults will initiate established cigarette smoking, underscoring the need to address the effects of this tobacco marketing tactic.

Relationships examined: Parent and child readiness to change and sociodemographic characteristics in family based weight loss treatment.

BACKGROUND: Family based treatment is an effective, multipronged approach to address obesity as it plagues families. OBJECTIVE: To investigate the relationships among sociodemographic characteristics (e.g., education and income), body mass index (BMI) and race/ethnicity with readiness to change for parents enrolled in the Primary care pediatrics, Learning, Activity and Nutrition (PLAN) study. METHODS: Multivariate linear regressions tested two hypotheses: (1) White parents will have higher levels of baseline readiness to change, when compared to Black parents; (2) parents with higher income and education will have higher levels of readiness to change at baseline. RESULTS: A positive relationship exists between baseline parent BMI and readiness to change (Pearson correlation, 0.09, p < 0.05); statistically significant relationships exist between parent education level (-0.14, p < 0.05), income (0.04, p < 0.05) and readiness to change. Additionally, a statistically significant relationship exists, with both White (ß, -0.10, p < 0.05), and Other, non-Hispanic (-0.10, p < 0.05) parents exhibiting lower readiness to change than Black, non-Hispanic parents. Child data did not indicate significant relationships between race/ethnicity and readiness to change. CONCLUSIONS: Results demonstrate that investigators should consider sociodemographic characteristic factors and different levels of readiness to change in participants enrolling in obesity interventions.

Longitudinal Association Between Exclusive and Dual Use of Cigarettes and Electronic Nicotine Delivery Systems and Asthma Among U.S. Adolescents.

PURPOSE: Electronic Nicotine Delivery Systems (ENDS) use among adolescents has increased greatly over the past decade, but its impact on chronic respiratory health conditions, like asthma, is not fully understood. METHODS: We examined data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study using discrete time hazard models to analyze the association between time-varying tobacco product use and incident diagnosed asthma among adolescents aged 12-17 years at baseline. We lagged the time-varying exposure variable by one wave and categorized respondents by current use status (1+ days in the past 30 days): never or non-current, exclusive cigarette, exclusive ENDS, and dual cigarette and ENDS use. We also controlled for sociodemographic (age, sex, race/ethnicity, parental education) and other risk factors (urban/rural setting, secondhand smoke exposure, household combustible tobacco use, body mass index). RESULTS: At baseline, over half the analytic sample (n = 9,141) was 15-17 years old (50.4%), female (50.2%), and non-Hispanic White (55.3%). Adolescents who exclusively smoked cigarettes had a statistically significant higher risk of incident diagnosed asthma at follow-up (adjusted Hazard Ratio (aHR): 1.68, 95% confidence interval (CI): 1.21-2.32) compared to those not currently using cigarettes or ENDS, but adolescents using ENDS exclusively (aHR: 1.25, 95% CI: 0.77-2.04) or in combination with cigarettes (aHR: 1.54, 95% CI: 0.92-2.57) did not. DISCUSSION: Short-term exclusive cigarette use was associated with a higher risk of incident diagnosed asthma over five years of follow-up among adolescents. We did not find conclusive evidence for an association between exclusive ENDS or dual use and incident diagnosed asthma.

Family-Based Behavioral Treatment for Childhood Obesity Implemented in Pediatric Primary Care: A Randomized Clinical Trial.

Importance: Intensive behavioral interventions for childhood overweight and obesity are recommended by national guidelines, but are currently offered primarily in specialty clinics. Evidence is lacking on their effectiveness in pediatric primary care settings. Objective: To evaluate the effects of family-based treatment for overweight or obesity implemented in pediatric primary care on children and their parents and siblings. Design, Setting, and Participants: This randomized clinical trial in 4 US settings enrolled 452 children aged 6 to 12 years with overweight or obesity, their parents, and 106 siblings. Participants were assigned to undergo family-based treatment or usual care and were followed up for 24 months. The trial was conducted from November 2017 through August 2021. Interventions: Family-based treatment used a variety of behavioral techniques to develop healthy eating, physical activity, and parenting behaviors within families. The treatment goal was 26 sessions over a 24-month period with a coach trained in behavior change methods; the number of sessions was individualized based on family progress. Main Outcomes and Measures: The primary outcome was the child's change from baseline to 24 months in the percentage above the median body mass index (BMI) in the general US population normalized for age and sex. Secondary outcomes were the changes in this measure for siblings and in BMI for parents. Results: Among 452 enrolled child-parent dyads, 226 were randomized to undergo family-based treatment and 226 to undergo usual care (child mean [SD] age, 9.8 [1.9] years; 53% female; mean percentage above median BMI, 59.4% [n = 27.0]; 153 [27.2%] were Black and 258 [57.1%] were White); 106 siblings were included. At 24 months, children receiving family-based treatment had better weight outcomes than those receiving usual care based on the difference in change in percentage above median BMI (-6.21% [95% CI, -10.14% to -2.29%]). Longitudinal growth models found that children, parents, and siblings undergoing family-based treatment all had outcomes superior to usual care that were evident at 6 months and maintained through 24 months (0- to 24-month changes in percentage above median BMI for family-based treatment and usual care were 0.00% [95% CI, -2.20% to 2.20%] vs 6.48% [95% CI, 4.35%-8.61%] for children; -1.05% [95% CI, -3.79% to 1.69%] vs 2.92% [95% CI, 0.58%-5.26%] for parents; and 0.03% [95% CI, -3.03% to 3.10%] vs 5.35% [95% CI, 2.70%-8.00%] for siblings). Conclusions and Relevance: Family-based treatment for childhood overweight and obesity was successfully implemented in pediatric primary care settings and led to improved weight outcomes over 24 months for children and parents. Siblings who were not directly treated also had improved weight outcomes, suggesting that this treatment may offer a novel approach for families with multiple children. Trial Registration: ClinicalTrials.gov Identifier: NCT02873715.

Milestones for neurosurgery sub-interns: a novel evaluation tool to quantitatively differentiate residency applicants.

OBJECTIVE: The study objective was to create a novel milestones evaluation form for neurosurgery sub-interns and assess its potential as a quantitative and standardized performance assessment to compare potential residency applicants. In this pilot study, the authors aimed to determine the form's interrater reliability, relationship to percentile assignments in the neurosurgery standardized letter of recommendation (SLOR), ability to quantitatively differentiate tiers of students, and ease of use. METHODS: Medical student milestones were either adapted from the resident Neurological Surgery Milestones or created de novo to evaluate a student's medical knowledge, procedural aptitude, professionalism, interpersonal and communication skills, and evidence-based practice and improvement. Four milestone levels were defined, corresponding to estimated 3rd-year medical student through 2nd-year resident levels. Faculty and resident evaluations as well as student self-evaluations were completed for 35 sub-interns across 8 programs. A cumulative milestone score (CMS) was computed for each student. Student CMSs were compared both within and between programs. Interrater reliability was determined with Kendall's coefficient of concordance (Kendall's W). Student CMSs were compared against their percentile assignments in the SLOR using analysis of variance with post hoc testing. CMS-derived percentile rankings were assigned to quantitatively distinguish tiers of students. Students and faculty were surveyed on the form's usefulness. RESULTS: The average faculty rating overall was 3.20, similar to the estimated competency level of an intern. Student and faculty ratings were similar, whereas resident ratings were lower (p < 0.001). Students were rated most highly in coachability and feedback (3.49 and 3.67, respectively) and lowest in bedside procedural aptitude (2.90 and 2.85, respectively) in both faculty and self-evaluations. The median CMS was 26.5 (IQR 21.75-29.75, range 14-32) with only 2 students (5.7%) achieving the highest rating of 32. Programs that evaluated the most students differentiated the highest-performing students from the lowest by at least 13 points. A program with 3 faculty raters demonstrated scoring agreement across 5 students (p = 0.024). The CMS differed significantly between SLOR percentile assignments, despite 25% of students being assigned to the top fifth percentile. CMS-driven percentile assignment significantly differentiated the bottom, middle, and top third of students (p < 0.001). Faculty and students strongly endorsed the milestones form. CONCLUSIONS: The medical student milestones form was well received and differentiated neurosurgery sub-interns both within and across programs. This form has potential as a replacement for numerical Step 1 scoring as a standardized, quantitative performance assessment for neurosurgery residency applicants.

Neuronal contact predicts connectivity in the C. elegans brain.

Axons must project to particular brain regions, contact adjacent neurons, and choose appropriate synaptic targets to form a nervous system. Multiple mechanisms have been proposed to explain synaptic partnership choice. In a "lock-and-key" mechanism, first proposed by Sperry's chemoaffinity model,1 a neuron selectively chooses a synaptic partner among several different, adjacent target cells, based on a specific molecular recognition code.2 Alternatively, Peters' rule posits that neurons indiscriminately form connections with other neuron types in their proximity; hence, neighborhood choice, determined by initial neuronal process outgrowth and position, is the main predictor of connectivity.3,4 However, whether Peters' rule plays an important role in synaptic wiring remains unresolved.5 To assess the nanoscale relationship between neuronal adjacency and connectivity, we evaluate the expansive set of C. elegans connectomes. We find that synaptic specificity can be accurately modeled as a process mediated by a neurite adjacency threshold and brain strata, offering strong support for Peters' rule as an organizational principle of C. elegans brain wiring.

Assessment of Electronic Nicotine Delivery Systems With Cigarette Use and Self-reported Wheezing in the US Adult Population.

Importance: The prevalence of electronic nicotine delivery systems (ENDS) use has increased, leading to a concern about their respiratory health outcomes. It is unclear whether ENDS use increases the risk of wheezing, a common symptom of respiratory conditions. Objective: To provide an analysis of the longitudinal association between ENDS and cigarette use and self-reported wheezing among US adults. Design, Setting, and Participants: The US nationally representative Population Assessment of Tobacco and Health (PATH) Study was used. Longitudinal data for adults 18 years or older from wave 1 (2013-2014) to wave 5 (2018-2019) were analyzed. Data were analyzed from August 2021 to January 2023. Main Outcomes and Measures: The prevalence of self-reported wheezing (waves 2-5) was estimated for 6 strata of tobacco product use (never cigarette and noncurrent ENDS use, never cigarette and current ENDS use, current cigarette and noncurrent ENDS use, current cigarette and current ENDS use, former cigarette and noncurrent ENDS use, and former cigarette and current ENDS use). A generalized estimating equations framework evaluated the association between cigarette and ENDS use and self-reported wheezing at the subsequent wave. An interaction term between cigarette and ENDS use was added to estimate the association between joint cigarette and ENDS use categories and the association of ENDS within strata of cigarette use. Results: The analytical sample consisted of 17 075 US adults with a mean (SD) age of 45.4 (17) years, of whom 8922 (51%) were female and 10 242 (66%) were Non-Hispanic White. When compared with never cigarette and noncurrent ENDS use, the greatest association in reporting wheezing was for current cigarette and current ENDS use (adjusted odds ratio [AOR], 3.26; 95% CI, 2.82-3.77), which was similar to current cigarette and noncurrent ENDS use (AOR, 3.20; 95% CI, 2.91-3.51) and substantially greater than former cigarette and current ENDS use (AOR, 1.94; 95% CI, 1.57-2.41). Associations were small and not statistically significant for the odds of self-reported wheezing among never cigarette and current ENDS use when compared with never cigarette and noncurrent ENDS use (AOR, 1.20; 95% CI, 0.83-1.72), and for odds of wheezing and current cigarette and current ENDS use when compared with current cigarette and noncurrent ENDS use (AOR, 1.02; 95% CI, 0.91-1.15). Conclusions and Relevance: In this cohort study, exclusive ENDS use was not associated with an increase in the risk of self-reported wheezing. However, a small increase in risk between ENDS use and wheezing was reported by individuals who use cigarettes. This study adds to the literature about the potential health effects associated with ENDS use.

Longitudinal associations between exclusive, dual, and polytobacco use and asthma among US youth.

Little is known about the respiratory health effects of dual (two products) and polytobacco (three or more products) use among youth in the United States. Thus, we followed a longitudinal cohort of youth into adulthood using data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, examining incident asthma at each follow-up (Waves 2-5). We classified past 30-day tobacco use as 1) no products (never/former use), 2) exclusive cigarettes, 3) exclusive electronic nicotine delivery systems (ENDS), 4) exclusive other combustible (OC) tobacco products (cigars, hookah, pipe), 5) dual cigarettes/OC and ENDS, 6) dual cigarettes and OCs, and 7) polytobacco use (cigarettes, OCs, and ENDS). Using discrete time survival models, we analyzed the incidence of asthma across Waves 2-5, predicted by time-varying tobacco use lagged by one wave, and adjusted for potential baseline confounders. Asthma was reported by 574 of the 9141 respondents, with an average annual incidence of 1.44% (range 0.35% to 2.02%, Waves 2-5). In adjusted models, exclusive cigarette use (HR: 1.71, 95% CI: 1.11-2.64) and dual cigarette and OC use (HR: 2.78, 95% CI: 1.65-4.70) were associated with incident asthma compared to never/former use, while exclusive ENDS use (HR: 1.50, 95% CI: 0.92-2.44) and polytobacco use (HR: 1.95, 95% CI: 0.86-4.44) were not. To conclude, youth who use cigarettes with or without OCs had higher risk of incident asthma. Further longitudinal studies on the respiratory health effects of ENDS and dual/polytobacco use are needed as products continue to evolve.

Time-varying association between cigarette and ENDS use on incident hypertension among US adults: a prospective longitudinal study.

OBJECTIVE: Electronic nicotine delivery systems (ENDS) products have emerged as the most popular alternative to combustible cigarettes. However, ENDS products contain potentially dangerous toxicants and chemical compounds, and little is known about their health effects. The aim of the present study was to examine the prospective association between cigarette and ENDS use on self-reported incident hypertension. DESIGN: Longitudinal cohort study. SETTING: Nationally representative sample of the civilian, non-institutionalised population in the USA. PARTICIPANTS: 17 539 adults aged 18 or older who participated at follow-up and had no self-reported heart condition or previous diagnosis of hypertension or high cholesterol at baseline. MEASURES: We constructed a time-varying tobacco exposure, lagged by one wave, defined as no use, exclusive established use (every day or some days) of ENDS or cigarettes, and dual use. We controlled for demographics (age, sex, race/ethnicity and household income), clinical risk factors (family history of heart attack, obesity, diabetes and binge drinking) and smoking history (cigarette pack-years). OUTCOMES: Self-reported incident hypertension diagnosis. RESULTS: The self-reported incidence of hypertension was 3.7% between wave 2 and wave 5. At baseline, 18.0% (n=5570) of respondents exclusively smoked cigarettes; 1.1% (n=336) exclusively used ENDS; and 1.7% (n=570) were dual users. In adjusted models, exclusive cigarette use was associated with an increased risk of self-reported incident hypertension compared with non-use (adjusted HR (aHR) 1.21, 95% CI 1.06 to 1.38), while exclusive ENDS use (aHR 1.00, 95% CI 0.68 to 1.47) and dual use (aHR 1.15, 95% CI 0.87 to 1.52) were not. CONCLUSIONS: We found that smoking increased the risk of self-reported hypertension, but ENDS use did not. These results highlight the importance of using prospective longitudinal data to examine the health effects of ENDS use.