Augmentative biological control for squash bug (Hemiptera: Coreidae) using the egg parasitoid, Hadronotus pennsylvanicus (Hymenoptera: Scelionidae).

The squash bug, Anasa tristis (De Geer) (Hemiptera: Coreidae), is a serious pest of cucurbit crops across the United States. Conventional growers commonly use broad-spectrum insecticides to manage squash bugs, however organic growers lack these effective chemical tools and must rely on alternative management strategies. Biological control of A. tristis is largely understudied, specifically the potential of natural enemy, Hadronotus pennsylvanicus (Ashmead) (Hymenoptera: Scelionidae), as an augmentative biological control agent. For this reason, we performed early-season field releases of H. pennsylvanicus on organic farms in southeastern Virginia to test if this would improve A. tristis egg parasitism. We chose organic vegetable farms growing summer squash (Cucurbita pepo L.) as release sites and nearby Virginia Tech Agricultural Research Extension Centers (AREC) as no-release sites. Parasitoids were reared in the lab and deployed as parasitized egg masses (~2-3 females wasps/plant) in June 2020 and 2021. Before parasitoid deployment, host eggs collected from release and no-release sites displayed low levels of H. pennsylvanicus parasitism in 2020 (<21%) and 2021 (<8%). In both years, the percentage of A. tristis eggs parasitized within 2 weeks post deployment was significantly greater at release sites (~60%) than at no-release sites (~14%). High rates of H. pennsylvanicus parasitism (>72%) were further observed at release sites 4, 6, 8, and 10 weeks following parasitoid deployment. Our study demonstrates that releases of lab-reared H. pennsylvanicus can increase A. tristis egg parasitism rates and subsequently decrease successful nymph hatch rates in early summer squash plantings.

Precision Neoantigen Discovery Using Large-Scale Immunopeptidomes and Composite Modeling of MHC Peptide Presentation.

Major histocompatibility complex (MHC)-bound peptides that originate from tumor-specific genetic alterations, known as neoantigens, are an important class of anticancer therapeutic targets. Accurately predicting peptide presentation by MHC complexes is a key aspect of discovering therapeutically relevant neoantigens. Technological improvements in mass spectrometry-based immunopeptidomics and advanced modeling techniques have vastly improved MHC presentation prediction over the past 2 decades. However, improvement in the accuracy of prediction algorithms is needed for clinical applications like the development of personalized cancer vaccines, the discovery of biomarkers for response to immunotherapies, and the quantification of autoimmune risk in gene therapies. Toward this end, we generated allele-specific immunopeptidomics data using 25 monoallelic cell lines and created Systematic Human Leukocyte Antigen (HLA) Epitope Ranking Pan Algorithm (SHERPA), a pan-allelic MHC-peptide algorithm for predicting MHC-peptide binding and presentation. In contrast to previously published large-scale monoallelic data, we used an HLA-null K562 parental cell line and a stable transfection of HLA allele to better emulate native presentation. Our dataset includes five previously unprofiled alleles that expand MHC diversity in the training data and extend allelic coverage in underprofiled populations. To improve generalizability, SHERPA systematically integrates 128 monoallelic and 384 multiallelic samples with publicly available immunoproteomics data and binding assay data. Using this dataset, we developed two features that empirically estimate the propensities of genes and specific regions within gene bodies to engender immunopeptides to represent antigen processing. Using a composite model constructed with gradient boosting decision trees, multiallelic deconvolution, and 2.15 million peptides encompassing 167 alleles, we achieved a 1.44-fold improvement of positive predictive value compared with existing tools when evaluated on independent monoallelic datasets and a 1.17-fold improvement when evaluating on tumor samples. With a high degree of accuracy, SHERPA has the potential to enable precision neoantigen discovery for future clinical applications.

Lost reproductive value reveals a high burden of juvenile road mortality in a long-lived species.

Adult mortality is often the most sensitive vital rate affecting at-risk wildlife populations. Therefore, road ecology studies often focus on adult mortality despite the possibility for roads to be hazardous to juvenile individuals during natal dispersal. Failure to quantify concurrent variation in mortality risk and population sensitivity across demographic states can mislead the efforts to understand and mitigate the effects of population threats. To compare relative population impacts from road mortality among demographic classes, we weighted mortality observations by applying reproductive value analysis to quantify expected stage-specific contributions to population growth. We demonstrate this approach for snapping turtles (Chelydra serpentina) observed on roads at two focal sites in Ontario, Canada, where we collected data for both live and dead individuals observed on roads. We estimated reproductive values using stage-classified matrix models to compare relative population-level impacts of adult and juvenile mortality. Reproductive value analysis is a tractable approach to assessing demographically variable effects for applications covering large spatial scales, nondiscrete populations, or where abundance data are lacking. For one site with long-term life-history data, we compared demographic frequency on roads to expected general population frequencies predicted by the matrix model. Our application of reproductive value is sex specific but, as juvenile snapping turtles lack external secondary sex characters, we estimated the sex ratio of road-crossing juveniles after dissecting and sexing carcasses collected on roads at five sites across central Ontario, Canada. Juveniles were more abundant on roads than expected, suggesting a substantial dispersal contribution, and the road-killed juvenile sex ratio approached 1:1. A higher proportion of juveniles were also found dead compared with adults, and cumulative juvenile mortality had similar population-level importance as adult mortality. This suggests that the impact of roads needs to be considered across all life stages, even in wildlife species with slow life histories, such as snapping turtles, that are particularly sensitive to adult mortality.

Bibliometric investigation of the integration of animal personality in conservation contexts.

Consistent individual differences in behavior, commonly termed animal personality, are a widespread phenomenon across taxa that have important consequences for fitness, natural selection, and trophic interactions. Animal personality research may prove useful in several conservation contexts, but which contexts remains to be determined. We conducted a structured literature review of 654 studies identified by combining search terms for animal personality and various conservation subfields. We scored the relevance of personality and conservation issues for each study to identify which studies meaningfully integrated the 2 fields as opposed to surface-level connections or vague allusions. We found a taxonomic bias toward mammals (29% of all studies). Very few amphibian or reptile studies applied personality research to conservation issues (6% each). Climate change (21%), invasive species (15%), and captive breeding and reintroduction (13%) were the most abundant conservation subfields that occurred in our search, though a substantial proportion of these papers weakly integrated conservation and animal personality (climate change 54%, invasive species 51%, captive breeding and reintroduction 40%). Based on our results, we recommend that researchers strive for consistent and broadly applicable terminology when describing consistent behavioral differences to minimize confusion and improve the searchability of research. We identify several gaps in the literature that appear to be promising and fruitful avenues for future research, such as disease transmission as a function of sociability or exploration as a driver of space use in protected areas. Practitioners can begin informing future conservation efforts with knowledge gained from animal personality research.

Investigación bibliométrica sobre la integración de la personalidad animal a los contextos de conservación Resumen Las diferencias individuales y constantes en el comportamiento, comúnmente llamadas personalidad animal, son un fenómeno generalizado en los taxones con consecuencias importantes para la aptitud, selección natural e interacciones tróficas. Las investigaciones sobre la personalidad animal pueden ser útiles en varios contextos de conservación, aunque falta determinar cuáles son estos contextos. Realizamos una revisión literaria estructurada de 654 estudios identificados mediante la combinación de los términos de búsqueda para la personalidad animal y varios subcampos de la conservación. Puntuamos la relevancia de la personalidad y los temas de conservación en cada estudio para identificar cuáles de estos integraron significativamente a ambos campos, contrario a las conexiones a nivel superficial o alusiones vagas. Descubrimos un sesgo taxonómico por los mamíferos (29% de todos los estudios). Pocos estudios enfocados en anfibios o reptiles aplicaron un estudio de personalidad a los temas de conservación (6% para cada uno). El cambio climático (21%), las especies invasoras (15%) y la reproducción en cautiverio y las reintroducciones (13%) fueron los subcampos de conservación más abundantes que aparecieron en nuestra búsqueda, aunque una proporción significativa de estos artículos integraron muy poco a la conservación y la personalidad animal (cambio climático 54%, especies invasoras 51%, reproducción en cautiverio y reintroducciones 40%). Con base en nuestros resultados, recomendamos que los investigadores procuren tener terminologías consistentes y de aplicación generalizada cuando describan las diferencias conductuales para así minimizar las confusiones y facilitar la búsqueda durante la investigación. Identificamos varios vacíos en la literatura que prometen ser vías fructíferas para las investigaciones en el futuro, como la transmisión de enfermedades como una función sociable o la exploración como un impulsor del uso del espacio en las áreas protegidas. Los practicantes pueden comenzar por guiar los siguientes esfuerzos de conservación con el conocimiento obtenido de las investigaciones sobre la personalidad animal.

Multisite Performance Evaluation of the cobas 5800 System and Comparison to the cobas 6800/8800 Systems for Quantitative Measurement of HBV, HCV, and HIV-1 Viral Load.

The cobas 5800 System ("cobas 5800") is a new low- to mid-throughput PCR-based nucleic acid testing system which performs both qualitative and quantitative testing, including viral load (VL) determination. cobas 5800 shares numerous design elements and technical characteristics with the existing cobas 6800/8800 Systems. We compared HBV, HCV, and HIV-1 VL results from cobas 5800 in three different laboratories to those from the same specimens tested on a cobas 6800 system. We also assessed cobas 5800 assay reproducibility by repetitive testing of specimens with VL close to values used as thresholds for patient management or classification. The correlation between VL measurements generated using cobas 5800 versus 6800 was extremely high, with r2 correlation coefficients between 0.990 and 0.999 for the three targets at the different sites. The slope of the Deming regression line ranged from 0.994 (HBV, site 3) to 1.025 (HIV-1, site 1). The standard deviation values ranged from 0.04 to 0.19 log10 IU/mL for HBV, 0.06 to 0.33 log10 IU/mL for HCV, and 0.05 to 0.34 log10 copies/mL for HIV-1. In general, variability was higher at lower VL. Between 98.6% and 100% of results fell within the allowable total difference zone that defines expected variability on the existing 6800/8800 system. This multisite comparison study demonstrates equivalent performance of the new cobas 5800 system compared with cobas 6800. This establishes cobas 5800 as a new option for low- to mid-throughout laboratories seeking to optimize efficiency of their viral molecular testing. IMPORTANCE These are the first published data that demonstrate equivalent performance of the new cobas 5800 system compared with cobas 6800. This fulfills an unmet need for low- to mid-throughout laboratories seeking to optimize efficiency of their viral molecular testing.

Both the Squash Bug Anasa tristis and Horned Squash Bug Anasa armigera (Hemiptera: Coreidae) are Attracted to Vittatalactone, the Aggregation Pheromone of Striped Cucumber Beetle.

Vittatalactone, the aggregation pheromone of the striped cucumber beetle, Acalymma vittatum (F.) (Coleoptera: Chrysomelidae), is attractive to two species of squash bugs (Hemiptera: Coreidae), the squash bug Anasa tristis (DeGeer) and horned squash bug Anasa armigera (Say). In field trapping experiments in Maryland and Virginia, clear sticky traps baited with 1 mg of a synthetic 8-isomer mix of vittatalactone captured ~9× more of female A. tristis and of both sexes of A. armigera, whereas male A. tristis were not significantly attracted, compared to unbaited traps. A. armigera showed a distinct dose-response to vittatalactone lure loading in the late season, and this species was more attracted than A. tristis, based on comparison to captures from underneath wooden boards emplaced in adjacent fields. Results suggest that vittatalactone could be a 'keystone semiochemical' in colonization of cucurbit hosts by specialist herbivores, and may offer the opportunity for multi-species behavioral control as a component of integrated pest management in cucurbit crops.

Effect of Plastic Mulch Colors on Anasa tristis (Hemiptera: Coreidae) Population Dynamics in Summer Squash, Cucurbita pepo (Cucurbitales: Cucurbitaceae).

The squash bug, Anasa tristis (De Geer), is a serious pest of cucurbit crops across the United States, especially within summer squash (Cucurbita pepo L.) systems. Using their piercing sucking mouthparts, squash bugs feed on both leaf tissue and fruits, often leading to leaf necrosis, marketable fruit loss, and even plant death. To date, the relationship between squash bug presence and plasticulture has not been adequately investigated. This 2-yr study evaluated the effects of white, black, and reflective plastic mulch colors on the occurrence of all squash bug life stages and marketable zucchini yield in Virginia. In both years, A. tristis adults and egg masses were more numerous on zucchini plants grown in white and reflective plastic mulch compared to bare ground plants. Greater nymphal densities and marketable fruit yield were observed in certain plastic mulch treatments versus the bare ground treatment, yet these differences were not consistent in both years. Contrary to the repellency effects reflective mulches have on other cucurbit insect pests, our research suggests that reflective and other plastic mulch colors can negatively impact squash bug management, especially in regions with high A. tristis pressure. Our study offers new insights for cucurbit growers to use when considering whether they should implement plasticulture in their growing systems.

A machine learning algorithm with subclonal sensitivity reveals widespread pan-cancer human leukocyte antigen loss of heterozygosity.

Human leukocyte antigen loss of heterozygosity (HLA LOH) allows cancer cells to escape immune recognition by deleting HLA alleles, causing the suppressed presentation of tumor neoantigens. Despite its importance in immunotherapy response, few methods exist to detect HLA LOH, and their accuracy is not well understood. Here, we develop DASH (Deletion of Allele-Specific HLAs), a machine learning-based algorithm to detect HLA LOH from paired tumor-normal sequencing data. With cell line mixtures, we demonstrate increased sensitivity compared to previously published tools. Moreover, our patient-specific digital PCR validation approach provides a sensitive, robust orthogonal approach that could be used for clinical validation. Using DASH on 610 patients across 15 tumor types, we find that 18% of patients have HLA LOH. Moreover, we show inflated HLA LOH rates compared to genome-wide LOH and correlations between CD274 (encodes PD-L1) expression and microsatellite instability status, suggesting the HLA LOH is a key immune resistance strategy.

Prediction of Immunotherapy Response in Melanoma through Combined Modeling of Neoantigen Burden and Immune-Related Resistance Mechanisms.

PURPOSE: While immune checkpoint blockade (ICB) has become a pillar of cancer treatment, biomarkers that consistently predict patient response remain elusive due to the complex mechanisms driving immune response to tumors. We hypothesized that a multi-dimensional approach modeling both tumor and immune-related molecular mechanisms would better predict ICB response than simpler mutation-focused biomarkers, such as tumor mutational burden (TMB). EXPERIMENTAL DESIGN: Tumors from a cohort of patients with late-stage melanoma (n = 51) were profiled using an immune-enhanced exome and transcriptome platform. We demonstrate increasing predictive power with deeper modeling of neoantigens and immune-related resistance mechanisms to ICB. RESULTS: Our neoantigen burden score, which integrates both exome and transcriptome features, more significantly stratified responders and nonresponders (P = 0.016) than TMB alone (P = 0.049). Extension of this model to include immune-related resistance mechanisms affecting the antigen presentation machinery, such as HLA allele-specific LOH, resulted in a composite neoantigen presentation score (NEOPS) that demonstrated further increased association with therapy response (P = 0.002). CONCLUSIONS: NEOPS proved the statistically strongest biomarker compared with all single-gene biomarkers, expression signatures, and TMB biomarkers evaluated in this cohort. Subsequent confirmation of these findings in an independent cohort of patients (n = 110) suggests that NEOPS is a robust, novel biomarker of ICB response in melanoma.

Use of Acute Psychiatric Hospitalisation: A Study of the Factors Influencing Decisions to Arrange Acute Admission to Inpatient Mental Health Facilities.

Background: Human decision-making involves a complex interplay of intra- and inter-personal factors. The decisions clinicians make in practise are subject to a wide range of influences. Admission to a psychiatric hospital is a major clinical intervention, but the decision-making processes involved in admissions remain unclear. Aims: To delineate the range of factors influencing clinicians' decisions to arrange acute psychiatric admissions. Methods: We undertook six focus groups with teams centrally involved in decisions to admit patients to hospital (crisis resolution home treatment, liaison psychiatry, approved mental health practitioners and consultant psychiatrists). The data were analysed using qualitative thematic analysis. Results: Our analysis of the data show a complex range of factors influencing decision-making that were categorised as those related to: (i) clinical and risk factors; (ii) fear/threat factors; (iii) interpersonal dynamics; (iv) contextual factors. Conclusions: Decisions to arrange acute admission to hospital are not just based on an appraisal of clinical and risk-related information. Emotional, interpersonal and contextual factors are also critical in decision-making. Delineating the breadth of factors that bear on clinical decision-making can inform approaches to (i) clinical decision-making research, (ii) the training and supervision of clinicians, and (iii) service delivery models.

Precision Neoantigen Discovery Using Large-scale Immunopeptidomes and Composite Modeling of MHC Peptide Presentation.

Major histocompatibility complex (MHC)-bound peptides that originate from tumor-specific genetic alterations, known as neoantigens, are an important class of anticancer therapeutic targets. Accurately predicting peptide presentation by MHC complexes is a key aspect of discovering therapeutically relevant neoantigens. Technological improvements in mass-spectrometry-based immunopeptidomics and advanced modeling techniques have vastly improved MHC presentation prediction over the past two decades. However, improvement in the sensitivity and specificity of prediction algorithms is needed for clinical applications such as the development of personalized cancer vaccines, the discovery of biomarkers for response to checkpoint blockade, and the quantification of autoimmune risk in gene therapies. Toward this end, we generated allele-specific immunopeptidomics data using 25 monoallelic cell lines and created Systematic HLA Epitope Ranking Pan Algorithm (SHERPA), a pan-allelic MHC-peptide algorithm for predicting MHC-peptide binding and presentation. In contrast to previously published large-scale monoallelic data, we used an HLA-null K562 parental cell line and a stable transfection of HLA alleles to better emulate native presentation. Our dataset includes five previously unprofiled alleles that expand MHC-binding pocket diversity in the training data and extend allelic coverage in under profiled populations. To improve generalizability, SHERPA systematically integrates 128 monoallelic and 384 multiallelic samples with publicly available immunoproteomics data and binding assay data. Using this dataset, we developed two features that empirically estimate the propensities of genes and specific regions within gene bodies to engender immunopeptides to represent antigen processing. Using a composite model constructed with gradient boosting decision trees, multiallelic deconvolution, and 2.15 million peptides encompassing 167 alleles, we achieved a 1.44-fold improvement of positive predictive value compared with existing tools when evaluated on independent monoallelic datasets and a 1.15-fold improvement when evaluating on tumor samples. With a high degree of accuracy, SHERPA has the potential to enable precision neoantigen discovery for future clinical applications.

Approaches to triage optimization in HPV primary screening: Extended genotyping and p16/Ki-67 dual-stained cytology-Retrospective insights from ATHENA.

The objective of our study was to assess the performance of different triage strategies for high-risk human papillomavirus (hrHPV)-positive results utilizing either extended genotyping or a p16/Ki-67 dual-stained cytology (DS) approach, with or without partial genotyping. A subset of women with hrHPV infections participating in the Addressing the Need for Advanced HPV Diagnostics (ATHENA) study were analyzed to determine the number of cervical intraepithelial neoplasia grade 3 or worse (≥CIN3) cases detected, and the absolute risk for ≥CIN3 of each genotype. A clinical utility table was constructed to compare the impact of different triage strategies. In all, 2,339 women with single-genotype hrHPV infections were identified. Among these were 171 ≥CIN3 cases. The U.S. Food and Drug Administration (FDA)-approved algorithm (HPV16/18 positive, or 12-other hrHPV positive and Pap positive, i.e., ≥ atypical squamous cells of undetermined significance) for primary HPV screening detected 132/171 (77.2%) ≥CIN3 cases and required 964 colposcopies (colposcopies per ≥CIN3 ratio: 7.3). An approach that uses DS instead of cytology in the FDA-approved algorithm detected 147/171 (86.0%) ≥CIN3 cases, requiring 1,012 colposcopies (ratio: 6.9). Utilizing DS for triage of all hrHPV-positive women identified 126/171 (73.7%) ≥CIN3 cases, requiring 640 colposcopies (ratio: 5.1). A strategy that detected HPV16/18/31/33/35+ captured 130/171 (76.0%) ≥CIN3 cases, requiring 1,025 colposcopies (ratio: 7.9). Inclusion of additional genotypes resulted in greater disease detection at the expense of higher colposcopy ratios. Substituting cytology with a DS triage approach improved disease detection and the colposcopy detection rate. Further reduction of colposcopy rates can be achieved by using DS without partial genotyping. Extended genotyping strategies can identify a comparable number of cases but requires an increased number of colposcopies.

Host Kairomones Influence Searching Behavior of Trissolcus japonicus (Hymenoptera: Scelionidae), a Parasitoid of Halyomorpha halys (Heteroptera: Pentatomidae).

The brown marmorated stink bug, Halyomorpha halys (Stål), is a highly polyphagous species native to Asia that has become a serious invasive agricultural and nuisance pest across North America and Europe. Classical biological control host range evaluations have revealed egg parasitoid Trissolcus japonicus (Ashmead) to be the primary candidate biocontrol agent for field release against H. halys. However, these evaluations only provide us with the physiological host range of T. japonicus. Other Trissolcus species have demonstrated that contact kairomones from different host species elicit varied responses in the parasitoids' host foraging behaviors. To assess T. japonicus response to host kairomones, mated naive females were exposed to leaf surfaces contaminated with adult kairomones from its preferred host, H. halys, or from a native nontarget host, Podisus maculiventris (Say) (Heteroptera: Pentatomidae). Red maple, apple, and soybean were used as plant substrate treatments. The wasp's residence time on the leaf surface, linear walking velocity, and angular walking velocity were observed and measured using Noldus EthoVision XT tracking software. Within each leaf treatment, T. japonicus displayed stronger behavioral responses on leaves contaminated with contact kairomones from H. halys. The parasitoid resided on H. halys contaminated leaves for approximately twice as a long as it did on P. maculiventris contaminated leaves. Further, both species' kairomones elicited significant decreases in parasitoid walking velocity on all tested substrate types. Overall, our study suggests that kairomone-based behavioral studies can be used to further evaluate the host specificity of T. japonicus and can be an invaluable supplement to classical biocontrol host range testing regimes.

Approaches to Assessment of Muscle Mass and Myosteatosis on Computed Tomography: A Systematic Review.

BACKGROUND/OBJECTIVE: There is increasing use of computed tomography (CT) in sarcopenia research using a wide variety of techniques. We performed a systematic review of the CT literature to identify the differences between approaches used. METHODS: A comprehensive search of PubMed from 1983 to 2017 was performed to identify studies that used CT muscle measurements to assess muscle mass and myosteatosis. The CT protocols were evaluated based on anatomic landmark(s), thresholding, muscle(s) segmented, key measurement (ie, muscle attenuation, cross-sectional area, volume), derived variables, and analysis software. From the described search, 657 articles were identified and 388 studies met inclusion criteria for this systematic review. RESULTS: Muscle mass was more commonly assessed than myosteatosis (330 vs. 125). The most commonly assessed muscle or muscle groups were total abdominal wall musculature (142/330 and 49/125 for muscle mass and myosteatosis, respectively) and total thigh musculature (90/330 and 48/125). The most commonly used landmark in the abdomen was the L3 vertebra (123/142 and 45/49 for muscle mass and myosteatosis, respectively). Skeletal muscle index and intermuscular adipose tissue were the most commonly used measures of abdominal wall muscle mass (114/142) and myosteatosis (27/49), respectively. Cut points varied across studies. A significant majority of studies failed to report important CT technical parameters, such as use of intravenous contrast and slice thickness (94% and 63%, respectively). CONCLUSIONS: There is considerable variation in the CT approaches used for the assessment of muscle mass and myosteatosis. There is a need to develop consensus for CT-based evaluation of sarcopenia and myosteatosis.

Related to Anxiety: Arbitrarily Applicable Relational Responding and Experimental Psychopathology Research on Fear and Avoidance.

Humans have an unparalleled ability to engage in arbitrarily applicable relational responding (AARR). One of the consequences of this ability to spontaneously combine and relate events from the past, present, and future may, in fact, be a propensity to suffer. For instance, maladaptive fear and avoidance of remote or derived threats may actually perpetuate anxiety. In this narrative review, we consider contemporary AARR research on fear and avoidance as it relates to anxiety. We first describe laboratory-based research on the emergent spread of fear- and avoidance-eliciting functions in humans. Next, we consider the validity of AARR research on fear and avoidance and address the therapeutic implications of the work. Finally, we outline challenges and opportunities for a greater synthesis between behavior analysis research on AARR and experimental psychopathology.

How much do cancer specialists earn? A comparison of physician fees and remuneration in oncology and radiology in high-income countries.

The main driver of higher spending on health care in the US is believed to be substantially higher fees paid to US physicians in comparison with other countries. We aim to compare physician incomes in radiology and oncology considering differences in relation to fees paid, physician capacity and volume of services provided in five countries: the United States, Canada, Australia, France and the United Kingdom. The fee for a consultation with a specialist in oncology varies threefold across countries, and more than fourfold for chemotherapy. There is also a three to fourfold variation in fees for ultrasound and CT scans. Physician earnings in the US are greater than in other countries in both oncology and radiology, more than three times higher than in the UK; Canadian oncologists and radiologists earn considerably more than their European counterparts. Although challenging, benchmarking earnings and fees for similar health care activities across countries, and understanding the factors that explain any differences, can provide valuable insights for policy makers trying to enhance efficiency and quality in service delivery, especially in the face of rising care costs.

Aseptic and Bacterial Meningitis: Evaluation, Treatment, and Prevention.

The etiologies of meningitis range in severity from benign and self-limited to life-threatening with potentially severe morbidity. Bacterial meningitis is a medical emergency that requires prompt recognition and treatment. Mortality remains high despite the introduction of vaccinations for common pathogens that have reduced the incidence of meningitis worldwide. Aseptic meningitis is the most common form of meningitis with an annual incidence of 7.6 per 100,000 adults. Most cases of aseptic meningitis are viral and require supportive care. Viral meningitis is generally self-limited with a good prognosis. Examination maneuvers such as Kernig sign or Brudzinski sign may not be useful to differentiate bacterial from aseptic meningitis because of variable sensitivity and specificity. Because clinical findings are also unreliable, the diagnosis relies on the examination of cerebrospinal fluid obtained from lumbar puncture. Delayed initiation of antibiotics can worsen mortality. Treatment should be started promptly in cases where transfer, imaging, or lumbar puncture may slow a definitive diagnosis. Empiric antibiotics should be directed toward the most likely pathogens and should be adjusted by patient age and risk factors. Dexamethasone should be administered to children and adults with suspected bacterial meningitis before or at the time of initiation of antibiotics. Vaccination against the most common pathogens that cause bacterial meningitis is recommended. Chemoprophylaxis of close contacts is helpful in preventing additional infections.