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STUDY DESIGN: Retrospective study with epidemiologic analysis of public Medicare data. OBJECTIVE: This study seeks to utilize geospatial analysis to identify distinct trends in lumbar fusion incidence and techniques in Medicare populations. SUMMARY OF BACKGROUND DATA: With an aging population and new technologies, lumbar fusion is an increasingly common procedure. There is controversy, however, regarding which indications and techniques achieve optimal outcomes, leading to significant intersurgeon variation and potential national disparities in care. MATERIALS AND METHODS: Medicare billing datasets were supplemented with Census Bureau socioeconomic data from 2013 to 2020. These databases listed lumbar fusions billed to Medicare by location, specialty, and technique. Hotspots and coldspots of lumbar fusion incidence and technique choice were identified with county-level analysis and compared with Mann-Whitney U . A linear regression of fusion incidence and a logistic regression of lumbar fusion hotspots/coldspots were also calculated. RESULTS: Between 2013 and 2020, 624,850 lumbar fusions were billed to Medicare. Lumbar fusion hotspots performed fusions at nearly five times the incidence of coldspots (101.6-21.1 fusions per 100,000 Medicare members) and were located in the Midwest, Colorado, and Virginia while coldspots were in California, Florida, Wisconsin, and the Northeast. Posterior and posterolateral fusion were the most favored techniques, with hotspots in the Northeast. Combined posterior and posterolateral fusion and posterior interbody fusion was the second most favored technique, predominantly in Illinois, Missouri, Arkansas, and Colorado. CONCLUSIONS: The geographic distribution of lumbar fusions correlates with variations in residency training, fellowship, and specialty. The geospatial patterning in both utilization and technique reflects a lack of consensus in the application of lumbar fusion. The strong variance in utilization is a potentially worrying finding that could suggest that the nonstandardization of lumbar fusion indication has led to both overtreatment and undertreatment across the nation. LEVEL OF EVIDENCE: Level 3-retrospective.

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OBJECTIVE: The objective of this study is to investigate whether self-disclosed disability and self-reported program access are associated with measures of empathy and burnout in a national sample of US medical students. METHODS: The authors obtained data from students who responded to the Association of Medical Colleges (AAMC) Year 2 Questionnaire (Y2Q) in 2019 and 2020. Data included demographic characteristics, personal variables, learning environment indicators, measures of burnout (Oldenburg Burnout Inventory for Medical Students), empathy (Interpersonal Reactivity Index) and disability-related questions, including self-reported disability, disability category and program access. Associations between disability status, program access, empathy and burnout were assessed using multivariable logistic regression models accounting for YQ2 demographic, personal-related and learning environment measures. RESULTS: Overall, 23 898 (54.2%) provided disability data and were included. Of those, 2438 (10.2%) self-reported a disability. Most medical students with disabilities (SWD) self-reported having program access through accommodations (1215 [49.8%]) or that accommodations were not required for access (824 [33.8%]). Multivariable models identified that compared with students without disabilities, SWD with and without program access presented higher odds of high exhaustion (1.50 [95% CI, 1.34-1.69] and 2.59 [95% CI, 1.93-3.49], respectively) and lower odds of low empathy (0.75 [95% CI, 0.67-.85] and 0.68 [95% CI, 0.52-0.90], respectively). In contrast, multivariable models for disengagement identified that SWD reporting lack of program access presented higher odds of high disengagement compared to students without disabilities (1.43 [95% CI, 1.09-1.87], whereas SWD with program access did not (1.09 [95% CI, 0.97-1.22]). CONCLUSIONS: Despite higher odds of high exhaustion, SWD were less likely to present low empathy regardless of program access, and SWD with program access did not differ from students without disabilities in terms of disengagement. These findings add to our understanding of the characteristics and experiences of SWD including their contributions as empathic future physicians.

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INTRODUCTION: Technical standards document US medical school's nonacademic criteria necessary for admission, persistence, and graduation and communicate the school's commitment to disability inclusion and accommodation but are considered one of the largest barriers for students with disabilities. Calls for more inclusive technical standards have increased in recent years, yet the impact of this work on changing technical standards has not been measured.The establishment of 15 new US MD- and DO-granting medical schools between 2017 to 2020 offered a unique opportunity to evaluate differences in the inclusive nature of newly developed technical standards. METHOD: We conducted a document analysis of 15 newly formed medical schools' technical standards to determine the availability and inclusive nature of the standards as they pertain to students with sensory and mobility disabilities. Technical standards were coded for: ease of obtaining technical standards, the school's stated willingness to provide reasonable accommodations, the origin of responsibility for accommodation request and implementation, and the school's openness to intermediaries or auxiliary aids. RESULTS: Of the 15 schools, 73% of the technical standards were not easy to locate online. Few (13%) included language that support disability accommodations. Most (73%) used language that was coded as 'restrictive' for students with physical or sensory disabilities. Coding of the newly accredited US MD and DO medical schools suggests that newly created technical standards are more restrictive than those in previous studies. CONCLUSIONS: Efforts to create more inclusive technical standards have not yet been realized. Newly formed US MD- and DO-granting medical schools may perpetuate historically restrictive technical standards that serve as barriers to applicants with disabilities. Future research should evaluate the role of medical school accrediting bodies to go beyond simply requiring technical standards to ensuring that the standards are readily available and appropriately convey the availability of reasonable accommodations for students with disabilities.

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Nicotinic ganglionic acetylcholine receptor autoantibodies (alpha-3-AChR Ab) are associated with paraneoplastic syndromes when present in low elevations. These antibodies can be tested for as part of an autoimmune encephalopathy panel in neuropsychiatric patients; a mildly elevated titre of alpha-3-AChR Ab that may start as an incidental finding can lead to the diagnosis of a previously undetected cancer. While alpha-3-AChR Ab are most typically associated with thymomas and small cell lung cancer, the presence of these antibodies can suggest a diverse range of other cancers. This case presents a patient with longstanding neuropsychiatric symptoms and possible functional hypothyroidism for whom a low elevation in alpha-3-AChR Ab led to the finding of papillary thyroid carcinoma.

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The Radiative-Convective Equilibrium Model Intercomparison Project (RCEMIP) is an intercomparison of multiple types of numerical models configured in radiative-convective equilibrium (RCE). RCE is an idealization of the tropical atmosphere that has long been used to study basic questions in climate science. Here, we employ RCE to investigate the role that clouds and convective activity play in determining cloud feedbacks, climate sensitivity, the state of convective aggregation, and the equilibrium climate. RCEMIP is unique among intercomparisons in its inclusion of a wide range of model types, including atmospheric general circulation models (GCMs), single column models (SCMs), cloud-resolving models (CRMs), large eddy simulations (LES), and global cloud-resolving models (GCRMs). The first results are presented from the RCEMIP ensemble of more than 30 models. While there are large differences across the RCEMIP ensemble in the representation of mean profiles of temperature, humidity, and cloudiness, in a majority of models anvil clouds rise, warm, and decrease in area coverage in response to an increase in sea surface temperature (SST). Nearly all models exhibit self-aggregation in large domains and agree that self-aggregation acts to dry and warm the troposphere, reduce high cloudiness, and increase cooling to space. The degree of self-aggregation exhibits no clear tendency with warming. There is a wide range of climate sensitivities, but models with parameterized convection tend to have lower climate sensitivities than models with explicit convection. In models with parameterized convection, aggregated simulations have lower climate sensitivities than unaggregated simulations.