A Stepwise Approach to a Career in Translational Research

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This chapter outlines a stepwise approach to building clinical research careers in this arena of bedside-to-bench and back form of clinical investigation. For the purposes of this chapter, a relatively restricted definition will apply, referring specifically to that subset of human investigations that address the “first translational block.” This term refers to that form of clinical research that focuses on the increasingly dynamic interface between bedside and bench. Careers in translational research are uniquely challenging and rewarding. Continually updating technological tools, reeducating oneself across an entire career, juggling the conflicting mandates of teaching, patient care, and research, and repeatedly competing for peer-reviewed funding are not for the faint of heart. However, research at the translational interface represents one of the most deeply satisfying careers that exists in academic medicine. The leverage is vast and the ability to potentially contribute to the alleviation of human suffering is irresistibly attractive, making all of the challenges seemingly small compared to the opportunity to accomplish a greater good in this pathway. This subset of clinical investigation stands in contrast to the “second translational block,” a term coined by the Institute of Medicine's Clinical Research Roundtable to refer to the difficulties encountered in achieving widespread implementation of treatments previously determined to be safe and efficacious in randomized clinical trials into everyday medical practice.

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Drug delivery systems are developed to maximize drug efficacy and minimize side effects. As drug delivery technologies improve, the drug becomes safer and more comfortable for patients to use. During the last seven decades, extraordinary progress has been made in drug delivery technologies, such as systems for long-term delivery for months and years, localized delivery, and targeted delivery. The advances, however, will face a next phase considering the future technologies we need to overcome many physicochemical barriers for new formulation development and biological unknowns for treating various diseases. For immediate and long-term progress into the future, the drug delivery field should use time and resources for more translatable research ideas. The drug delivery discipline has to continue working on basic, applied, translational, and clinical research in a concerted manner to produce drug delivery systems that work for patients. It is a time to focus our attention on things that matter. It is also a time to develop realistic research goals and outcomes, diversify drug delivery technologies, and take the collective responsibility for our actions.
Medical scientists and public health policy makers are increasingly concerned that the scientific discoveries of the past generation are failing to be translated efficiently into tangible human benefit. This concern has generated several initiatives, including the Clinical Research Roundtable at the Institute of Medicine, which first convened in June 2000. Representatives from a diverse group of stakeholders in the nation's clinical research enterprise have collaborated to address the issues it faces. The context of clinical research is increasingly encumbered by high costs, slow results, lack of funding, regulatory burdens, fragmented infrastructure, incompatible databases, and a shortage of qualified investigators and willing participants. These factors have contributed to 2 major obstacles, or translational blocks: impeding the translation of basic science discoveries into clinical studies and of clinical studies into medical practice and health decision making in systems of care. Considering data from across the entire health care system, it has become clear that these 2 translational blocks can be removed only by the collaborative efforts of multiple system stakeholders. The goal of this article is to articulate the 4 central challenges facing clinical research at present—public participation, information systems, workforce training, and funding; to make recommendations about how they might be addressed by particular stakeholders; and to invite a broader, participatory dialogue with a view to improving the overall performance of the US clinical research enterprise.
125I-Labeled low density lipoproteins were found to associate with monolayers of cultured normal fibroblasts by two processes—one of high affinity and one of low affinity. The high affinity association appeared to represent binding of the low density lipoprotein to specific receptor sites on the cell surface. This binding process exhibited saturation kinetics at low concentrations of the lipoprotein and competition by related molecules such as very low density lipoproteins. In addition, this process was stimulated by the presence of calcium in the culture medium and could be destroyed by limited treatment of the cells with pronase. The other process, designated low affinity uptake, may represent nonspecific endocytosis since the uptake was proportional to the lipoprotein concentration in the medium with no apparent saturation and because it showed no competition by very low density lipoproteins, no stimulation by calcium, and no destruction by pronase treatment. The 125I-labeled low density lipoproteins associated with normal cells by either the high or low affinity process were degraded by proteolysis to trichloroacetic acid-soluble material, most of which was 125I-tyrosine. In normal cells, binding of low density lipoproteins to the high affinity membrane receptor sites appears to serve two functions: (a) it results in suppression of the synthesis of 3-hydroxy-3-methylglutaryl coenzyme A reductase, the rate-controlling enzyme in cholesterol biosynthesis, and (b) it facilitates the degradation of low density lipoproteins when they are present in the culture medium at low concentrations (i.e. high affinity degradation). Cultured cells from subjects with the homozygous form of familial hypercholesterolemia, which were found to lack the high affinity binding process, were resistant to suppression of 3-hydroxy-3-methylglutaryl coenzyme A reductase activity by low density lipoproteins and were also deficient in high affinity degradation. On the other hand, these mutant cells showed a normal low affinity uptake of low density lipoproteins and were able to degrade these lipoproteins when they were present in the culture medium at high concentrations. The possibility is raised, therefore, that a prerequisite for the regulation of cholestero-genesis in cultured fibroblasts is the initial binding of low density lipoproteins to the high affinity surface receptor sites and that a defect in this process represents the primary genetic abnormality in the disorder familial hypercholesterolemia.
A low plasma level of low-density lipoprotein (LDL) cholesterol is associated with reduced risk of coronary heart disease (CHD), but the effect of lifelong reductions in plasma LDL cholesterol is not known. We examined the effect of DNA-sequence variations that reduce plasma levels of LDL cholesterol on the incidence of coronary events in a large population. We compared the incidence of CHD (myocardial infarction, fatal CHD, or coronary revascularization) over a 15-year interval in the Atherosclerosis Risk in Communities study according to the presence or absence of sequence variants in the proprotein convertase subtilisin/kexin type 9 serine protease gene (PCSK9) that are associated with reduced plasma levels of LDL cholesterol. Of the 3363 black subjects examined, 2.6 percent had nonsense mutations in PCSK9; these mutations were associated with a 28 percent reduction in mean LDL cholesterol and an 88 percent reduction in the risk of CHD (P=0.008 for the reduction; hazard ratio, 0.11; 95 percent confidence interval, 0.02 to 0.81; P=0.03). Of the 9524 white subjects examined, 3.2 percent had a sequence variation in PCSK9 that was associated with a 15 percent reduction in LDL cholesterol and a 47 percent reduction in the risk of CHD (hazard ratio, 0.50; 95 percent confidence interval, 0.32 to 0.79; P=0.003). These data indicate that moderate lifelong reduction in the plasma level of LDL cholesterol is associated with a substantial reduction in the incidence of coronary events, even in populations with a high prevalence of non-lipid-related cardiovascular risk factors.