Advancing Inclusive Research: Establishing Collaborative Strategies to Improve Diversity in Clinical Trials

Well-characterized disparities in clinical research have disproportionately affected patients of color, particularly in underserved communities. To tackle these barriers, Genentech formed the External Council for Advancing Inclusive Research, a 14-person committee dedicated to developing strategies to increase clinical research participation. To help improve the recruitment and retention of patients of color, this article chronicles our efforts to tangibly address the clinical research barriers at the system, study, and patient levels over the last four years. These efforts are one of the initial steps to fully realize the promise of personalized health care and provide increased patient benefit at less cost to society. Instead of simply acknowledging the problem, here we illuminate the collaborative and multilevel strategies that have been effective in delivering meaningful progress for patients.

Interactions with pocket proteins contribute to the role of human papillomavirus type 16 E7 in the papillomavirus life cycle

Human papillomaviruses (HPVs), most commonly the HPV16 genotype, are the principle etiological determinant for cervical cancer, a common cancer worldwide resulting in over 200,000 deaths annually. The oncogenic properties of HPVs are attributable in part to the virally encoded protein E7, best known for its ability to bind to and induce the degradation of the retinoblastoma tumor suppressor, pRb, and related "pocket proteins" p107 and p130. Previously, we defined a role for E7 in the productive stage of the HPV16 life cycle, which takes place in stratified squamous epithelia. HPV perturbs the normal processes of cell growth and differentiation of stratified squamous epithelia. HPVs reprogram cells to support continued DNA synthesis and inhibit their differentiation in the suprabasal compartment of the epithelia, where cells normally have withdrawn from the cell cycle and initiated a well-defined pattern of terminal differentiation. These virus-induced perturbations, which contribute to the production of progeny HPVs, are dependent on E7. In this study, we define the mechanism of action by which E7 contributes to the productive stage of the HPV16 life cycle. We found that the ability of HPV16 to reprogram suprabasal cells to support DNA synthesis correlates with E7's ability to bind pocket proteins but not its ability to induce their degradation. In contrast, the ability of HPV16 to perturb differentiation correlated with both E7's binding to and degradation of pocket proteins. These data indicate that different hallmarks of the productive stage of the HPV16 life cycle rely upon different sets of requirements for E7.

Avian sarcoma and leukosis virus cytopathic effect in the absence of TVB death domain signaling

The cytopathic effect (CPE) seen with some subgroups of avian sarcoma and leukosis virus (ASLV) is associated with viral Env activation of the death-promoting activity of TVB (a tumor necrosis factor receptor-related receptor that is most closely related to mammalian TNF-related apoptosis-inducing ligand [TRAIL] receptors) and with viral superinfection leading to unintegrated viral DNA (UVD) accumulation, which is presumed to activate a cellular DNA damage response. In this study, we employed cells that express signaling-deficient ASLV receptors to demonstrate that an ASLV CPE can be uncoupled from the death-promoting functions of the TVB receptor. However, these cell-killing events were associated with much higher levels of viral superinfection and DNA accumulation than those seen when the virus used signaling-competent TVB receptors. These findings suggest that a putative cellular DNA damage response that is activated by UVD accumulation might act in concert with the death-signaling pathways activated by Env-TVB interactions to trigger cell death. Such a model is consistent with the well-established synergy that exists between TRAIL-signaling pathways and DNA damage responses which is currently being exploited in cancer therapy regimens.

R-Ras promotes focal adhesion formation through focal adhesion kinase and p130(Cas) by a novel mechanism that differs from integrins

R-Ras regulates integrin function, but its effects on integrin signaling pathways have not been well described. We demonstrate that activation of R-Ras promoted focal adhesion formation and altered localization of the alpha2beta1 integrin from cell-cell to cell-matrix adhesions in breast epithelial cells. Constitutively activated R-Ras(38V) dramatically enhanced focal adhesion kinase (FAK) and p130(Cas) phosphorylation upon collagen stimulation or clustering of the alpha2beta1 integrin, even in the absence of increased ligand binding. Signaling events downstream of R-Ras differed from integrins and K-Ras, since pharmacological inhibition of Src or disruption of actin inhibited integrin-mediated FAK and p130(Cas) phosphorylation, focal adhesion formation, and migration in control and K-Ras(12V)-expressing cells but had minimal effect in cells expressing R-Ras(38V). Therefore, signaling from R-Ras to FAK and p130(Cas) has a component that is Src independent and not through classic integrin signaling pathways and a component that is Src dependent. R-Ras effector domain mutants and pharmacological inhibition suggest a partial role for phosphatidylinositol 3-kinase (PI3K), but not Raf, in R-Ras signaling to FAK and p130(Cas). However, PI3K cannot account for the Src-independent pathway, since simultaneous inhibition of both PI3K and Src did not completely block effects of R-Ras on FAK phosphorylation. Our results suggest that R-Ras promotes focal adhesion formation by signaling to FAK and p130(Cas) through a novel mechanism that differs from but synergizes with the alpha2beta1 integrin.

More than a pump: the endocrine functions of the heart

The endocrine functions of all tissues, including the heart, are being delineated in more detail as our understanding of cellular biology unfolds. Natriuretic peptides form an important counterregulatory system to balance the effects of sympathetic neurohormones. As we learn to intervene with therapeutic manipulations of this system, critical care practitioners will be involved in the assessment, monitoring, and evaluation of new cardiovascular therapies.

More than a pump: the endocrine functions of the heart

The endocrine functions of all tissues, including the heart, are being delineated in more detail as our understanding of cellular biology unfolds. Natriuretic peptides form an important counterregulatory system to balance the effects of sympathetic neurohormones. As we learn to intervene with therapeutic manipulations of this system, critical care practitioners will be involved in the assessment, monitoring, and evaluation of new cardiovascular therapies.

A physiological model for tert-amyl methyl ether and tert-amyl alcohol: hypothesis testing of model structures

The oxygenate tert-amyl methyl ether (TAME) is a gasoline fuel additive used to reduce carbon monoxide in automobile emissions. To evaluate the relative health risk of TAME as a gasoline additive, information is needed on its pharmacokinetics and toxicity. The objective of this study was to use a physiologically-based pharmacokinetic (PBPK) model to describe the disposition of TAME and its major metabolite, tert-amyl alcohol (TAA), in male Fischer-344 rats. The model compartments for TAME and TAA were flow-limited. The TAME physiological model had 6 compartments: lung, liver, rapidly perfused tissues, slowly perfused tissues, fat, and kidney. The TAA model had 3 compartments: lung, liver, and total-body water. The 2 models were linked through metabolism of TAME to TAA in the liver. Model simulations were compared with data on blood concentrations of TAME and TAA taken from male Fischer-344 rats during and after a 6-hour inhalation exposure to 2500, 500, or 100 ppm TAME. The PBPK model predicted TAME pharmacokinetics when 2 saturable pathways for TAME oxidation were included. The TAA model, which included pathways for oxidation and glucuronide conjugation of TAA, underpredicted the experimental data collected at later times postexposure. To account for biological processes occurring during this time, three hypotheses were developed: nonspecific binding of TAA, diffusion-limited transport of TAA, and enterohepatic circulation of TAA glucuronide. These hypotheses were tested using three different model structures. Visual inspection and statistical evaluation involving maximum likelihood techniques indicated that the model incorporating nonspecific binding of TAA provided the best fit to the data. A correct model structure, based upon experimental data, statistical analyses, and biological interpretation, will allow a more accurate extrapolation to humans and, consequently, a greater understanding of human risk from exposure to TAME.

Rapid identification of respiratory viruses: impact on isolation practices and transmission among immunocompromised pediatric patients

OBJECTIVE

To determine whether empiric isolation of patients with acute respiratory virus infection symptoms could be discontinued when preliminary shell vial cultures were negative, and the impact of this approach on hospital resources.

DESIGN

In 1993, we retrospectively reviewed respiratory virus test results from 1992 to 1993 and extended data collection prospectively through the 1993 to 1994 season. The rapid test and 48-hour shell vial results were compared to a standard of rapid test plus 5-day shell vial culture results to determine the sensitivity and specificity of these "preliminary" results.

SETTING

A 400-bed tertiary referral research hospital.

PATIENTS

Patients from any inpatient unit or clinic with acute respiratory virus infection symptoms who had a specimen submitted for respiratory virus culture. Patients were placed on empiric respiratory isolation pending culture results.

RESULTS

The overall sensitivity of the combined rapid and 48-hour culture results in adults and children was 97%. All 15 pediatric patients with respiratory syncytial virus infection who had specimens submitted on first suspicion of respiratory virus infection were positive by rapid test. Culture results were positive within 48 hours for 100% of patients with influenza A (15 patients), influenza B (6), and parainfluenza (18) viruses. Of 59 pediatric inpatients who were isolated empirically awaiting 5-day culture results, 31 (52%) ultimately were determined to be culture negative.

CONCLUSIONS

Empiric isolation of symptomatic children can be discontinued at 48 hours when both the rapid test and the early culture results are negative. Our institution would have saved 93 days of unnecessary isolation over 2 years had such a policy been in place.

Normotensive blacks have heightened sympathetic response to cold pressor test

The purpose of this study was to compare sympathetic nerve activity responses to the cold pressor test in black and white normotensive subjects. We recorded muscle sympathetic nerve activity (microneurography of the peroneal nerve), arterial blood pressure, and heart rate in 9 normotensive American blacks (24 +/- 2 years, mean +/- SEM) and 10 normotensive American whites (28 +/- 2 years) at rest and during hand immersion in ice water (cold pressor test). Body weight was not different in the two groups (72.4 +/- 3.7 versus 74.1 +/- 3.8 kg, black versus white subjects). During supine rest, mean arterial pressure (92 +/- 2 versus 93 +/- 3 mm Hg, black versus white), heart rate (66 +/- 4 versus 62 +/- 3 beats per minute, black versus white), and muscle sympathetic nerve burst frequency (12 +/- 2 versus 17 +/- 3 bursts per minute, black versus white) were not different in the two groups. During the cold pressor test, mean arterial pressure, heart rate, and muscle sympathetic nerve activity increased from supine rest in both groups. The magnitudes of increases in mean arterial pressure and total minute muscle sympathetic nerve activity were significantly greater in blacks than whites (33.5 +/- 3 versus 22.4 +/- 3 mm Hg and 416 +/- 24% versus 243 +/- 31% of control, respectively, black versus white, P < .05). The increases in heart rate were most significantly different for the two groups. These data suggest that the enhanced pressor response to cold stress observed in normotensive blacks is attributable to greater increases in peripheral sympathetic nerve activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastrointestinal complications in shock

The gut organs are vulnerable to injury during shock because of ischemia and reperfusion of the microcirculation. These injuries result in upper GI hemorrhage, liver dysfunction, and pancreatic and mesenteric necrosis. Toxic mediators, released via lymph drainage and with reperfusion, contribute to the failure of other organs and the development of refractory shock. Until single organ perfusion can be measured, the primary goal of care is to maintain systemic perfusion. Secondary goals are to decrease hydrogen ion accumulation, minimize pancreatic stimulation, remove hepatotoxic agents, and reduce blood bacteria. Gut ischemia is simply one piece of the puzzle in the multiple organ response to reduced systemic oxygenation and perfusion that characterizes the clinical syndrome of shock.