Interrogating the Value of Return of Results for Diverse Populations: Perspectives from Precision Medicine Researchers

BACKGROUND

Over the last decade, the return of results (ROR) in precision medicine research (PMR) has become increasingly routine. Calls for individual rights to research results have extended the "duty to report" from clinically useful genetic information to traits and ancestry results. ROR has thus been reframed as inherently beneficial to research participants, without a needed focus on who benefits and how. This paper addresses this gap, particularly in the context of PMR aimed at increasing participant diversity, by providing investigator and researcher perspectives on and questions about the assumed value of ROR in PMR.

METHODS

Semi-structured interviews with a purposive sample of investigators and researchers across federally funded PMR studies in three national consortia, as well as observations of study activities, focused on how PM researchers conceptualize diversity and implement inclusive practices across research stages, including navigating ROR.

RESULTS

Interviewees (1) validated the value of ROR as a benefit of PMR, while others (2) questioned the benefit of clinically actionable results to individuals in the absence of sufficient resources for translating findings into health care for diverse and disadvantaged populations; (3) expressed uncertainties in applying the presumed value of ROR as a benefit for non-clinical results; and (4) and debated when the promise of the value of ROR may undermine trust in PMR, and divert efforts to return value beyond ROR.

CONCLUSIONS

Conceptualizations of diversity and inclusion among PM researchers and investigators raise unique ethical questions where unexamined assumptions of the value of ROR inform study recruitment efforts to enroll minoritized and under-represented populations. A lack of consideration for resources and infrastructure necessary to translate ROR into actionable information may hinder trustworthy community-research relationships. Thus, we argue for a more intentional interrogation of ROR practices as an offer of benefit and for whom.

Rethinking Benefit and Responsibility in the Context of Diversity: Perspectives from the Front Lines of Precision Medicine Research

INTRODUCTION

Federal agencies have instituted guidelines to prioritize the enrollment and retention of diverse participants in precision medicine research (PMR). Prior studies examining participation of minoritized communities have shown that potential benefits represent a key determinant. Human subject research guidance, however, conceptualizes potential benefits narrowly, emphasizing generalized advances in medical knowledge. Further, few studies have provided qualitative data that critically examine how the concept of "benefit" is interpreted or challenged in the context of research practice. This paper examines the experiences of PMR investigators and frontline research staff to understand how standard approaches to benefit are received, contested, and negotiated "on the ground."

METHODS

Findings are drawn from a qualitative project conducted across five US-based, federally funded PMR studies. Data collection included 125 in-depth interviews with a purposive sample of investigators, research staff, community advisory board members, and NIH program officers associated with these PMR studies.

RESULTS

Researchers report that the standard approach to benefit - which relies on the premise of altruism and the promise of incrementally advancing scientific knowledge - is frequently contested. Researchers experience moral distress over the unmet clinical, psychosocial, and material needs within the communities they are engaging. Many believe the broader research enterprise has a responsibility to better address these needs.

CONCLUSION

Researchers frequently take issue with and sometimes negotiate what is owed to participants and to their communities in exchange for the data they provide. These experiences of moral distress and these improvisations warrant systematic redress, not by individual researchers but by the broader research ethics infrastructure.

Community Engagement in Precision Medicine Research: Organizational Practices and Their Impacts for Equity

BACKGROUND

In the wake of mandates for biomedical research to increase participation by members of historically underrepresented populations, community engagement (CE) has emerged as a key intervention to help achieve this goal.

METHODS

Using interviews, observations, and document analysis, we examine how stakeholders in precision medicine research understand and seek to put into practice ideas about who to engage, how engagement should be conducted, and what engagement is for.

RESULTS

We find that ad hoc, opportunistic, and instrumental approaches to CE exacted significant consequences for the time and resources devoted to engagement and the ultimate impacts it has on research. Critical differences emerged when engagement and research decisionmaking were integrated with each other versus occurring in parallel, separate parts of the study organization, and whether community members had the ability to determine which issues would be brought to them for consideration or to revise or even veto proposals made upstream based on criteria that mattered to them. CE was understood to have a range of purposes, from instrumentally facilitating recruitment and data collection, to advancing community priorities and concerns, to furthering long-term investments in relationships with and changes in communities. These choices about who to engage, what engagement activities to support, how to solicit and integrate community input into the workflow of the study, and what CE was for were often conditioned upon preexisting perceptions and upstream decisions about study goals, competing priorities, and resource availability.

CONCLUSIONS

Upstream choices about CE and constraints of time and resources cascade into tradeoffs that often culminated in "pantomime community engagement." This approach can create downstream costs when engagement is experienced as improvised and sporadic. Transformations are needed for CE to be seen as a necessary scientific investment and part of the scientific process.

Targeting Representation: Interpreting Calls for Diversity in Precision Medicine Research

Scientists have identified a "diversity gap" in genetic samples and health data, which have been drawn predominantly from individuals of European ancestry, as posing an existential threat to the promise of precision medicine. Inadequate inclusion as articulated by scientists, policymakers, and ethicists has prompted large-scale initiatives aimed at recruiting populations historically underrepresented in biomedical research. Despite explicit calls to increase diversity, the meaning of diversity - which dimensions matter for what outcomes and why - remain strikingly imprecise. Drawing on our document review and qualitative data from observations and interviews of funders and research teams involved in five precision medicine research (PMR) projects, we note that calls for increasing diversity often focus on "representation" as the goal of recruitment. The language of representation is used flexibly to refer to two objectives: achieving sufficient genetic variation across populations and including historically disenfranchised groups in research. We argue that these dual understandings of representation are more than rhetorical slippage, but rather allow for the contemporary collection of samples and data from marginalized populations to stand in as correcting historical exclusion of social groups towards addressing health inequity. We trace the unresolved historical debates over how and to what extent researchers should procure diversity in PMR and how they contributed to ongoing uncertainty about what axes of diversity matter and why. We argue that ambiguity in the meaning of representation at the outset of a study contributes to a lack of clear conceptualization of diversity downstream throughout subsequent phases of the study.

Strategies of inclusion: The tradeoffs of pursuing "baked in" diversity through place-based recruitment

US funding agencies have begun to institutionalize expectations that biomedical studies achieve defined thresholds for diversity among research participants, including in precision medicine research (PMR). In this paper, we examine how practices of recruitment have unfolded in the wake of these diversity mandates. We find that a very common approach to seeking diverse participants leverages understandings of spatial, geographic, and site diversity as proxies and access points for participant diversity. That is, PMR investigators recruit from a diverse sampling of geographic areas, neighborhoods, sites, and institutional settings as both opportunistic but also meaningful ways to "bake in" participant diversity. In this way, logics of geographic and institutional diversity shift the question from who to recruit, to where. However, despite seeing geographic and site diversity as social and scientific 'goods' in the abstract and as key to getting diverse participants, PMR teams told us that working with diverse sites was often difficult in practice due to constraints in funding, time, and personnel, and inadequate research infrastructures and capacity. Thus, the ways in which these geographic and institutional diversity strategies were implemented resulted ultimately in limiting the meaningful inclusion of populations and organizations that had not previously participated in biomedical research and reproduced the inclusion of institutions that are already represented. These prevailing assumptions about and practices of "baked-in" diversity in fact exacerbate and produce other forms of inequity, in research capacity and research representation. These findings underscore how structural inequities in research resources must be addressed for diversity to be achieved in both research sites and research participants.

Beyond inclusion: Enacting team equity in precision medicine research

PURPOSE

To identify meanings of and challenges to enacting equitable diversification of genomics research, and specifically precision medicine research (PMR), teams.

METHODS

We conducted in-depth interviews with 102 individuals involved in three U.S.-based precision medicine research consortia and conducted over 400 observation hours of their working group meetings, consortium-wide meetings, and conference presentations. We also reviewed published reports on genomic workforce diversity (WFD), particularly those relevant to the PMR community.

RESULTS

Our study finds that many PMR teams encounter challenges as they strive to achieve equitable diversification on scientific teams. Interviewees articulated that underrepresented team members were often hired to increase the study's capacity to recruit diverse research participants, but are limited to on-the-ground staff positions with little influence over study design. We find existing hierarchies and power structures in the academic research ecosystem compound challenges for equitable diversification.

CONCLUSION

Our results suggest that meaningful diversification of PMR teams will only be possible when team equity is prioritized as a core value in academic research communities.

A minimally invasive approach to pilonidal disease with endoscopic pilonidal sinus treatment (EPSiT): a single-center case series with long-term results

BACKGROUND

Minimally invasive techniques for treating pilonidal disease are safe and effective alternatives to conventional surgery, with improved recovery time, cosmetic results, and pain control. The aim of this study was to evaluate the 5-year surgical outcomes of a single-center case series treated with endoscopic pilonidal sinus treatment (EPSiT).

METHODS

We conducted a retrospective single-center analysis of all patients treated with EPSiT, by a single surgical team, from March 2015 to December 2019, for primary or recurrent pilonidal disease. The primary outcomes were recurrence, persistence and treatment failure. The secondary outcomes were postoperative pain, painkiller use, time off work, satisfaction, complications, wound healing time, time to persistence or recurrence.

RESULTS

Forty-two patients underwent 46 EPSiT procedures [34 males, 8 females, median age 25 (IQR 13.75) years] for primary (47.8%) or recurrent pilonidal disease (52.2%). All patients completed the follow-up [median 62 (IQR 43) months]. The single procedure healing rate was 76.1%. The healing rate for the first procedures plus the second EPSiT procedure (performed in 4 cases) was 83.3%. Among the 46 EPSiT procedures, we recorded six cases of persistence (13.0%) and five cases of recurrence (10.9%) The median operative time was 32.5 (IQR 18.75) minutes, the median pain score (visual analog scale) in week 1 was 2 (IQR 2), and the median time off work was 4 (IQR 2) days. Four patients (8.7%) experienced complications: serosanguineous (n = 2) or seropurulent discharge (n = 2). The satisfaction rate was 95.7%.

CONCLUSIONS

In our experience, EPSiT is safe, well accepted. and associated with a low level of postoperative pain, short hospitalization, short time off work, as well as optimal cosmetic results. Its failure rate is similar to that of excisional surgery.

Retroperitoneal lipoma. Unusual presentation with detrusor instability

Retroperitoneal lipomas are a heterogeneous group of mesenchymal tumors. They are usually large and occur most frequently in the retroperitoneal, perineal and pelvic regions. Lipomas grow slowly surrounding the retroperitoneal and pelvic organs, with a displacement of bowel and vascular axis. A case of a 61-year-old male patient which referred urinary frequency, urgency and nocturia is presented. Urodynamics evidenced a detrusor instability in a low capacity bladder. CT scan demonstrated a bladder dome compression due to a huge retroperitoneal mass extending from the right hepatic lobe to the hypogastric region and the right thigh. Surgical complete resection was performed: histology demonstrated a lipoma with areas of well differentiated myxoid degeneration. After surgery the irritative urinary symptoms disappeared. This is the first case described in literature of detrusor instability due to bladder compression by retroperitoneal lipoma.

Bahren types III and IVa testicular vein anomalies as a reason for failure in left idiopathic varicocele retrograde sclerotherapy. Ontogenic discussion and clinical implications

Left testicular vein anatomy has received more attention due to the presence of competent or incompetent venous valves and bypassing anastomoses, which are involved in venographic diagnosis and embolisation of varicocele. The left gonadal vein develops, in both males and females, between the 5th and 7th intrauterine weeks, being derived from the distal or postrenal portion of the left subcardinal vein. The varicocele aetiologic hypothesis leads to ontogenetic disturbances in the development of the secondary venous system. Retrograde testicular venography shows the precise anatomy of the left pampiniform plexus, while anterograde testicular venography identifies the presence of the valve and possible continence. In the present case sclerotherapy could not be achieved due to testicular vein anomalies. Sclerotherapy versus surgical high ligature of the left testicular vein in cases of left idiopathic varicocele with testicular vein anomalies is discussed.

[Inflammatory pseudotumor of the bladder: etiopathologic and clinical features]

The Authors present a case of inflammatory pseudotumour (IPT) of the urinary bladder occurring in a 57-year-old female patient, who was referred to our department with haematuria, stranguria and hypogastric pain. Ultrasonographic, radiological and endoscopic examinations showed a sessile, ulcerated, easily bleeding bladder formation; urinary cytology revealed no atypical transitional cells. Abdomino-pelvic computed tomography analysis showed thickening of the bladder walls and infiltration of the perivesical fat. Histopathologically, the formation was indicated as an inflammatory pseudotumour (IPT) of the bladder. The patient underwent TURB (transurethral resection of the bladder) and was discharged clinically healed on postoperative day 4. A one-year follow up revealed no evidence of recurrence. On the basis of their experience and a thorough review of the literature review, the Authors discuss the clinico-pathological features of IPT of the bladder and the possible factors involved in the malignant transformation of IPT. In conclusion, the benign nature of the lesion is stressed.

Prostatic small cell carcinoma diagnosed by tru-cut needle biopsy: discussion of clinico-pathological findings

The small cell carcinoma is a neuroendocrine tumour characterised by an aggressive clinical course and a high mortality rate. It occurs most commonly in the lung. Small cell carcinomas originating in the genitourinary system have been diagnosed with increasing frequency in recent years, because of the use of immunohistochemistry. Prostatic small cell carcinomas present the same biological behavior and similar histological, immunohistochemical and ultrastructural features to small cell carcinomas of the lungs. We describe the clinico-pathological findings in a 65-year-old male patient with a diagnosis of prostatic small cell carcinoma, obtained by means of a tru-cut needle biopsy. We performed the immunohistochemical tests using neuron-specific enolase and chromogranin A antibodies, according to the literature. On the basis of our experience we stress the malignant features of small cell carcinoma and the difficulty in obtaining an early diagnosis and treatment because of the aggressive course of the lesion and the late symptomatology.

[Inverted papilloma of the bladder: observation of 3 clinical cases and discussion on their clinico-pathologic characteristics]

Three cases of urothelial inverted papilloma, detected in two female patients aged 32 and 31 years, respectively and in one 67-year-old male patient, are described. Inverted papilloma is a benign lesion which occurs in the urinary epithelium with a 20% incidence in comparison with other urothelial tumours. The male:female ratio is 3:1. The histological structure of urothelial inverted papilloma is similar to that of inverted papilloma of the nasal and paranasal sinuses. It presents interanastomosed epithelial cords, with transitional cells, which develop in the tunica propria connective tissue. Some cells are distributed in such a way as to constitute vacuolated glandular-like structures. The histogenetic origin of the lesion from Home subtrigonal or Albarran subcervical glands is debatable. Recent aetiological hypotheses have claimed that the origin of the lesion may be related to Brunn's nest hyperplasia and/or to chronic urothelial inflammation. The latter hypothesis would currently appear to be the most accredited: immunostaining for cytokeratins would tend to support a urothelial inflammatory aetiology. In our cases, we achieved a definitive diagnosis of inverted papilloma only at histology, because of the specificity of the echotomography and cystoscopy findings. Urinary cytology revealed only a large number of inflammatory cells with anaplastic elements, but without any more detailed morphological description. We performed a transurethral resection of the bladder (TURB) in all three patients: routine follow-up showed the absence of inverted papilloma relapses. On the basis of the above-mentioned data and a thorough review of the literature, we attempt to assess and classify the clinico-pathological findings and the aetiological hypotheses of urothelial inverted papilloma. In addition, the benign nature of the lesion and any malignant transformation factors are discussed.

[Thyroid nodules: comparison of preoperative and intraoperative needle aspirate and definite histological study]

The need to discover malignancy is the most challenging dilemma in the management of thyroid nodules, the most common endocrine disorders, affecting 4-5% of the general population. Malignancies account for only 2-3% of cases. The aim of our study was to evaluate the predictive value of preoperative fine-needle aspiration cytology (FNAC) in surgical decision making by evaluating the final pathologic diagnosis and comparing it to the preoperative and intraoperative diagnoses. We conducted a prospective study of 30 thyroid resections. The mean age was 49 years (range: 27 to 68 years). Preoperative physical and laboratory examinations, presenting symptoms, imaging studies and predictive values of preoperative and intraoperative FNAC were analyzed. The consistency of the lesion was strongly predictive of malignancy, when "hard". Single lesions were also predictive of malignancy. The diagnostic accuracy of preoperative FNAC vs intraoperative FNAC vs frozen section histopathology was 90% vs 100% vs 96.7%; sensitivity: 91.6% vs 100% vs 100%; specificity: 90.5% vs 100% vs 94.7%, while the positive predictive value was 84.6% vs 100% vs 91.7%, and the negative predictive value 95% vs 100% vs 100%. Ultrasound-guided preoperative FNAC showed high specificity, sensitivity and accuracy in diagnosing malignancy in thyroid nodules. Intraoperative FNAC was more accurate than intraoperative frozen sections in diagnosing malignancy in thyroid nodules.

Interposition vein cuff in infrainguinal prosthetic bypasses

The Authors describe the interposition vein cuff technique as an adjuvant method to infrainguinal prosthetic bypass grafts. The haemodynamic, mechanical and humoral factors thought to be involved in the beneficial effects of the vein cuff are herein discussed. The results of the main series suggest the use of this method particularly in patients without any available autologous vein conduit requiring a below-knee popliteal or crural reconstruction.

[Chronic viral hepatitis due to the hepatitis C virus (HCV): treatment experience with lymphoblast interferon-alpha]

Ten patients affected with HCV-related chronic hepatitis received alpha lymphoblastoid-IFN, 3 mU i.m. TW, for 12 months. We obtained: 4 complete responses, 5 partial responses, 1 non-response (therapy stopped after 3 months). During the fourteen months follow-up, 4 patients (1 complete responder, 3 partial responders) relapsed.

[Role of the cerebral CAT examination in the diagnosis of neurotoxoplasmosis]

A case of central nervous system toxoplasmosis is reported. Attention is called to the diagnosis of this infection; moreover, the authors emphasize the importance of the TAC brain for the diagnosis and evaluation of the clinical evolution and response to the therapy.

[On the subject of leptospirosis. Description of a case]

The Authors report a case of leptospirosis. Stress is laid on the sporadicity of this infection in their region; attention is also drawn to the variety of the clinical expression of this disease.

[An animal model for the study of liver regeneration by magnetic resonance imaging]

Liver regeneration after partial hepatectomy was studied in rats by means of magnetic resonance (MR) imaging and T1 relaxation time. Fourteen hepatectomized rats were compared to sham operated ones and to controls which had not undergone any surgical treatment. The animals were imaged at 0.5 T, and inversion recovery (IR) technique was employed at the T-null of liver before surgery. T1 was determined in vitro with spectroscopy. Regenerating rat liver exhibited a significantly high increase in MR signal intensity and T1 values (p less than 0.05) 24 hours after surgery, returning to baseline values at 2 weeks. Sham operated animals and controls did not exhibit significant changes in signal intensity from baseline values (p greater than 0.05). These findings suggest that MR imaging is able to detect the pathophysiological changes occurring in liver parenchyma during the regenerating process and to monitor different stages of the hyperplastic process.

[Clinico-epidemiologic considerations in cases of acute viral non-A, non-B hepatitis (NANB)]

Personal experience with a series of 69 cases of non-A, non-B viral hepatitis out of 164 cases of acute viral hepatitis observed at hospital admission between January 1985 and June 1988 is reported. Agreement is expressed with other Italian series as regards the incidence of sex, of the most involved age classes, of the most affected professional categories and of the incubation period of posttransfusional forms. The prevalence of sporadic forms over those transmitted intraparenterally and more prolonged course in icterus patients and in parenteral forms is pointed out.

[The epidemiology of non-A, non-B hepatitis (NANB). A review of the literature]

Non-A, non-B hepatitis (NANB) is, after type B hepatitis, the most frequently encountered form of hepatitis. Parenteral transmission and apparently nonparenteral or "sporadic" forms are described. The epidemiology of this new form of hepatitis is examined in the light of personal experience and of reported data.

[Induced pemphigus and brucellosis]

A case of induced pemphigus occurring in a patient affected with a brucellosis is reported with emphasis on the definitive remission of the pemphigus after antibiotic therapy against brucellosis and in the absence of corticosteroid treatment. Attention is also drawn to a possible autoimmune mechanism of the pemphigus triggered by brucellosis.

Purulent meningitis due to spontaneous anterior sacral meningocele perforation. Case report

A 36 year old woman with anterior sacral meningocele developed a purulent meningitis secondary to the rupture of the meningeal sac into the rectum. The value of neuroradialogical studies, especially CT, is emphasized.

[Visceral leishmaniasis as an opportunistic infection. Our experience]

A case of visceral leishmaniasis in a female patient suffering from acute nonlymphoid leukaemia is reported. Stress is laid on the atypical nature of the clinical picture, falsified by the underlying disease, and attention is called to the behaviour of Leishmania as an opportunistic agent in the immunodepressed host.

[Pneumocystis carinii: laboratory diagnosis. State of the art]

In the light of the international literature and personal observation, the diagnostic techniques employed in Pneumocystis Carinii Pneumonia (PCP), a major opportunistic infection of acquired immunodeficiency syndrome (AIDS) are reviewed.

[Behavior of serum immunoglobulins in boutonneuse fever]

The behaviour of serum immunoglobulins in 35 patients suffering from Mediterranean exanthematous has been studied. No particular quantitative or qualitative change lieve noted. Supported by the scanty and contrasting data in existing literature, it is maintained that aspecific immunological serum doses are of little use, but research is urged into specific antibodies by means of indirect immunofluorescence and the Elisa method.

[Hepatitis virus and pregnancy. Our experience]

The importance of perinatal infection in the mother-foetus transmission of HbsAg positive hepatitis is stressed. The role of type A hepatitis has no influence and that of the NANB is little known. The Authors maintain that in no case is the hepatitis virus a valid motive for the interruption of pregnancy, even when it occurs in the first months of gestation.

[Significance and limits of serum transaminases in the diagnosis of viral hepatitis]

The Authors considering four cases of obstructive jaundice with hepatocellular onset, point out the possibility of errors and of misleading diagnostic views resulting from the excessive credit given to the increase of serum transaminases also in viral hepatitis diagnosis.

[Humoral immunity in epidemic parotitis]

The authors have studied the behaviour of the Immunoglobulins and of the hemoagglutination-inhibiting and complement-fixing antibodies in 9 subjects suffering from a complicated form of parotitis and coming from the same epidemic focus. A considerable movement of antibodies was noticed, while contrary to the findings of other authors, an increase in the IgA was not evident.