Application of next-generation sequencing to improve cancer management: A review of the clinical effectiveness and cost-effectiveness.

Uptake of next-generation sequencing (NGS) has increased dramatically due to significant cost reductions and broader community acceptance of NGS. To systematically review the evidence on both the clinical effectiveness and the cost-effectiveness of applying NGS to cancer care. A systematic search for full-length original research articles on the clinical effectiveness and cost-effectiveness of NGS in MEDLINE and EMBASE. Articles that focussed on cancer care and involved the application of NGS were included for the review of clinical effectiveness. For the cost-effectiveness review, we only included the articles with economic evaluations of NGS in cancer care. We report the rate of successfully detecting mutations from the clinical studies. The incremental cost-effectiveness ratio and sensitivity analysis outcomes are reported for the cost-effectiveness articles. Fifty-six articles reported that sequencing patient samples using targeted gene panels, and 83% of the successfully sequenced patients harboured at least 1 mutation. Only 6 studies reported on the cost-effectiveness of the application of NGS in cancer care. NGS is an effective tool for identifying mutation in cancer patients. However, more rigorous cost-effectiveness studies of NGS applied to cancer management are needed to determine whether NGS can improve patient outcomes cost-effectively.

Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

After the publication of this protocol [1], our collaborator Prima Health solutions advised us of their intent to withdraw from the study.

The impact of poverty on self-efficacy: an Australian longitudinal study.

BACKGROUND: People with strong feelings of 'self-efficacy', i.e. how much a person feels they have control over their life, perform better in the workplace. However, little is known about negative influences on feelings of self-efficacy. In view of the increasing number of people whose income places them below the poverty line despite being in employment, poverty may negatively influence feelings of self-efficacy and hence workplace productivity. AIMS: To assess whether falling into poverty lowers self-efficacy. METHODS: Longitudinal analysis of waves 7 to 11 of the nationally representative Household, Income and Labour Dynamics in Australia (HILDA) survey, using linear regression models. RESULTS: Those who fell into multidimensional poverty (income poverty plus poor health or insufficient level of education attainment) had significantly lower self-efficacy scores (up to 18% lower (95% CI -31% to -1%, P < 0.05)) than those never in poverty, after accounting for initial self-efficacy score and other confounding factors. Income uniquely accounted for 3% of the variance in self-efficacy scores, physical health for 10%, mental health for 78% and education for 1%. CONCLUSIONS: Given the known links between self-efficacy and workplace productivity, workers who are below the poverty line may be at risk of poor productivity due to the experience of poverty. In addition to the poor outcomes from the employer's perceptive, this may also lead to a negative spiral for the employee.

Baby boomer retirement and the future of dentistry.

BACKGROUND: The dental workforce, like the Australian population, is ageing. As the large baby boomer cohort retires dental shortages will likely increase. METHODS: Australian Bureau of Statistics census data from 1986 to 2001 were used to examine ageing of the dental workforce and attrition of dentists aged 50 years and over. The number of dentists to retire was projected over the next 20 years. RESULTS: Since 1986, the dental workforce has aged significantly (p < 0.01). About half of the current dental workforce is projected to retire by 2026. Generation X dentists are significantly less likely to work long hours than the baby boomer cohort of dentists (p < 0.01). This is partly due to an increase in the proportion of women in the dental workforce and male Generation X dentists being less likely to work long hours (>41 per week) than male baby boomer dentists (p < 0.01). CONCLUSIONS: Ageing of the workforce will have an impact on dentistry later than on some other professions due to the 35 per cent of dentists who work beyond 65 years of age. Nonetheless, existing dental shortages are likely to be exacerbated over the short term by the 22 per cent of dentists projected to retire over the next 10 years.

Ageing of the baby boomer generation: how demographic change will impact on city and rural GP and nursing workforce.

OBJECTIVE: To compare the impact of ageing on the GP and nursing rural and city workforce. METHOD: Cohort analysis of Australian Bureau of Statistics census data. The data was used to examine the age distribution of the city and rural GP and nursing workforce; patterns of attrition for those 50 years and over; and the impact of changes in working hours. RESULTS: The rural GP and nursing workforce is significantly older than their city counterparts (p<0.001) with the 'baby boomer' generation making up 52% of city GPs but 59% of rural GPs in 2001. While a large proportion of city and rural GPs continued to work past the age of 65 years, rural GPs left the workforce at a significantly younger age than city doctors (p<0.001). Rural nurses are older than their city peers (p<0.001) but retire at an older age than city nurses (p<0.001). In 1986, a significantly higher proportion of rural GPs in all age cohorts worked more than 41 hours per week compared with their city counterparts (p<0.001). By 2001, rural 'generation X' GPs were no more likely to work long hours than those in the city (p<0.001). However, significantly more rural than city 'baby boomers' continued to work long hours. CONCLUSIONS: Rural GPs are retiring faster than city GPs and strategies to attract rural GPs and nurses will be critical to ensure adequate rural health care and that current rural workforce shortage do not worsen.

Determination of affinities of a panel of IgGs and Fabs for whole enveloped (influenza A) virions using surface plasmon resonance.

The affinity of a panel of neutralizing monoclonal IgGs and their Fab fragments has been measured for the first time with an enveloped type A influenza virus, by surface plasmon resonance (SPR) and the BIAlite instrument. Equilibrium constants could be calculated for four of the five mAbs tested. These were in the nanomolar range. The ranking order was very similar to that obtained with an affinity ELISA, (an equilibrium system) but as others have found, affinities were 2-10-fold lower as measured by SPR (a flow system). No data were obtained with mAb HC58 although it had one of the highest affinities using an ELISA format, and was 28-fold higher than another mAb (HC10) which gave good data by SPR. This may relate to the orientation of its binding on the virion surface. The Kdissoc. of the Fabs was only 3-10-fold higher compared to their IgGs. Fab from the lowest affinity IgG (HC10) could not be measured, possibly because it fell below the threshold for detection.

Generating a panel of highly specific antibodies to 20 human SH2 domains by phage display.

To demonstrate the utility of phage display in generating highly specific antibodies, affinity selections were conducted on 20 related Src Homology 2 (SH2) domains (ABL1, ABL2, BTK, BCAR3, CRK, FYN, GRB2, GRAP2, LYN, LCK, NCK1, PTPN11 C, PIK3R1 C, PLCgamma1 C, RASA1 C, SHC1, SH2D1A, SYK N, VAV1 and the tandem domains of ZAP70). The domains were expressed in Escherichia coli, purified and used in affinity selection experiments. In total, 1292/3800 of the resultant antibodies were shown to bind the target antigen. Of the 695 further evaluated in specificity ELISAs against all 20 SH2 domains, 379 antibodies were identified with unique specificity (i.e. monospecific). Sequence analysis revealed that there were at least 150 different clones with 1-19 different antibodies/antigen. This includes antibodies that distinguish between ABL1 and ABL2, despite their 89% sequence identity. Specificity was confirmed for many on protein arrays fabricated with 432 different proteins. Thus, even though the SH2 domains share a common three-dimensional structure and 20-89% identity at the primary structure level, we were able to isolate antibodies with exquisite specificity within this family of structurally related domains.

The health consequences of unemployment: the evidence.

Mathers and Schofield, from the Australian Institute of Health and Welfare, review recent studies, including Australian research, on the health effects of unemployment and the mechanisms by which unemployment causes adverse health outcomes. The relationship is complex: ill-health also causes unemployment, and confounding factors include socioeconomic status and lifestyle. However, longitudinal studies with a range of designs provide reasonably good evidence that unemployment itself is detrimental to health and has an impact on health outcomes--increasing mortality rates, causing physical and mental ill-health and greater use of health services.

Variations in the neutralizing and haemagglutination-inhibiting activities of five influenza A virus-specific IgGs and their antibody fragments.

Neutralization and haemagglutination-inhibition (HI) of a type A influenza virus by a panel of five monoclonal IgGs, their F(ab')2s, Fabs and Fabs+ anti-mouse Fab were compared. The MAbs were specific for antigenic sites A, B and D of the haemagglutinin. Activities of the IgGs varied by up to 6-fold on a molar basis, apart from the HI activity of HC58 which was > 100-fold lower. This was not due to low functional affinity as HC58 had the second highest value (nM) as determined by an equilibrium method with whole virions. Conversion to the F(ab')2 reduced neutralization and HI by only 2- to 6-fold, indicating that the Fc region had little involvement in these processes. However, all Fabs had low neutralization and HI activity compared with their IgGs, neutralization being reduced by 86 to > 1912-fold, and HI by 13 to > 69-fold. Although decreased, their affinities remained high, in the nM range. Neutralization and HI by three of the Fabs (HC2, HC3W and HC61) were restored by the addition of anti-Fab IgG; however, HC10 Fab+anti-Fab IgG still had no detectable neutralization activity but gave HI, and HC58 Fab+anti-Fab IgG had no detectable HI activity but neutralized to the same extent as its IgG. The different properties of the antibodies are discussed in the light of their known mechanisms of action: HI by steric blocking of attachment of virus to the red cell receptor, and neutralization by the inhibition of post-attachment events (HC2, HC10 and HC61). The data demonstrate just how variable are the antiviral properties of individual IgGs.

High and low efficiency neutralization epitopes on the haemagglutinin of type A influenza virus.

The relationship between the efficiency of the neutralization process and the affinity of five monoclonal IgG antibodies specific for the haemagglutinin of type A influenza virus has been investigated by determining their neutralization rate constants (Kneut.) and affinities (Kdissoc.). We addressed the hypothesis that if antibody affinity alone determined the efficiency of neutralization, then the Kneut.:Kdissoc. ratio would be the same for all antibodies. However, we found that the Kneut.:Kdissoc. ratio varied by up to 125-fold, suggesting that properties unique to the epitope are of major importance in determining the efficiency of neutralization. These data suggest that vaccines should preferentially stimulate antibodies to epitopes that mediate the most efficient neutralization, and that a high Kdissoc. should be an important but secondary consideration.

Four chimpanzee monoclonal antibodies isolated by phage display neutralize hepatitis a virus.

Chimpanzee immunoglobulins are virtually identical to human immunoglobulins and may have clinically useful applications. Four chimpanzee monoclonal antibodies (MAbs) to the hepatitis A virus (HAV) capsid were isolated from a combinatorial cDNA library of gamma1/kappa antibody genes using phage display. Competition assays indicated that three of the MAbs recognized the same or overlapping epitopes, whereas the fourth recognized a different, nonoverlapping epitope on the HAV capsid. All four MAbs neutralized the homologous HAV strain, HM-175, in a radioimmunofocus assay and two of the four MAbs neutralized a heterologous simian HAV strain, AGM-27. From these data, we conclude that the MAbs must recognize at least three epitopes on the HAV capsid. Furthermore, competition assays performed with neutralizing murine MAbs suggested that three of the chimpanzee MAbs recognized epitopes on the HAV capsid which have not been defined previously.

Identification by phage display and characterization of two neutralizing chimpanzee monoclonal antibodies to the hepatitis E virus capsid protein.

Two monoclonal antibodies (MAbs) against the ORF2 protein of the SAR-55 strain of hepatitis E virus (HEV) were isolated by phage display from a cDNA library of chimpanzee (Pan troglodytes) gamma1/kappa antibody genes. Both MAbs, HEV#4 and HEV#31, bound to reduced, denatured open reading frame 2 (ORF2) protein in a Western blot, suggesting that they recognize linear epitopes. The affinities (equilibrium dissociation constants, K(d)) for the SAR-55 ORF2 protein were 1.7 nM for HEV#4 and 5.4 nM for HEV#31. The two MAbs also reacted in an enzyme-linked immunosorbent assay with recombinant ORF2 protein from a heterologous HEV, the Meng strain. Each MAb blocked the subsequent binding of the other MAb to homologous ORF2 protein in indirect competition assays, suggesting that they recognize the same or overlapping epitopes. Radioimmunoprecipitation assays suggested that at least part of the linear epitope(s) recognized by the two MAbs is located between amino acids 578 and 607. MAbs were mixed with homologous HEV in vitro and then inoculated into rhesus monkeys (Macaca mulatta) to determine their neutralizing ability. Whereas all control animals developed hepatitis (elevated liver enzyme levels in serum) and seroconverted to HEV, those receiving an inoculum incubated with either HEV#4 or HEV#31 were not infected. Therefore, each MAb neutralized the SAR-55 strain of HEV in vitro.