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Immunotherapy utilizing Candida antigen is a relatively new option for the treatment of non genital warts. Recent studies identified in our search demonstrated 70% complete wart clearance after an average of three injections (12,13). Although the time to achieve complete clearance was not markedly different than any of the other therapies investigated, the minimal medication costs and limited number of office visits make it an attractive treatment option. An added benefit for the use of Candida immunotherapy lies in the finding that 78% of patients with complete resolution of their treated wart also had resolution of untreated distant warts (12). For some individuals with extensive wart burdens, i.e. greater than seven warts, this line of therapy may be even more attractive since the treatment of a single wart may yield complete resolution of the entire wart burden.

There are significant problems with the mechanisms by which conflicts of interest are currently managed and governed. In our view, finder''s fees and other controversial issues in research have often been de-tit with in isolation, and in a way sheltered from analyses which would open up the possibility of "legal interference." Discussions about finder''s fees and other recruitment incentives are often oriented solely by reference to institutional, national, and international ethics guidelines. They remain curiously silent on the parties'' legal obligations and potential legal sanctions. This reflects and encourages inordinate reliance on the overly general conflicts of interest rules in ethics guidelines, and on the inadequately regulated American (or largely unregulated Canadian) system of IRB review. Some legislated standards of professional conduct and court rulings provide much more stringent benchmarks for the behavior of physicians in research, but these have been largely ignored and inadequately enforced. This paper aims to create awareness of the seriousness of the issues surrounding finder''s fees, and to detail relevant ethical, legal, and policy standards. We argue that stricter oversight of conflicts of interest by institutional and regulatory authorities, and better enforcement of existing regulatory and legal remedies are needed to safeguard the rights and well-being of research subjects and to preserve the integrity of the medical profession and the research process. In addition, we point out that instances of concealed profiteering from research recruitment activities could attract criminal sanctions. This alone highlights the importance of professional organizations and funding and regulatory agencies turning their full attention to the development of adequate controls for recruitment activities.

METHODSStudy SitesWe initially selected 40 VA nursing homes for possible inclusion in the study. Nursing homes were selected so as to meet the following three characteristics. First, they were to represent diverse geographic areas. Second, they were to vary in size, with approximately half having fewer than 100 beds. Third, nursing homes were to differ in their quality of care as measured by the rate of pressure ulcer development calculated from an administrative database. Two nursing homes were dropped from this initial list because we could not identify a local liaison to assist with data collection, two were dropped due to delays in obtaining institutional approval, and one was dropped from the analyses due to its exceptionally small size, with resulting limited information on performance. Thus, our final sample consisted of 35 nursing homes.

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