Correction to: Picking and Choosing Among Phase I Trials

The article "Picking and Choosing Among Phase I Trials", written by Jill A. Fisher, Torin Monahan and Rebecca L. Walker, was originally published Online First without Open Access. After publication in volume 16, issue 4, page 535-549 the author decided to opt for Open Choice and to make the article an Open Access publication.

Speculating on Precarious Income: Finance Cultures and the Risky Strategies of Healthy Volunteers in Clinical Drug Trials

Speculation has become a normalized occupational strategy and quotidian economic rationality that extends throughout society. Although there are many contemporary articulations of speculation, this article focuses on contract labor as a domain of financialization. Seen through this lens, contract labor can be understood as a speculative investment strategy wherein individuals leverage whatever assets they have at their disposal-savings, time, bodily health-to capture economic advantages. In particular, we explore the speculative practices of healthy individuals who enroll in pharmaceutical drug trials as their primary or critical source of income. Mobilizing speculative logics to maximize the money they can earn from their clinical trial participation, these contract workers employ what we term a future-income-over-immediate-pay calculus. This speculative calculus valorizes fictional projections of significant long-term future income over present financial opportunities. For the economically precarious individuals in our study, we argue that rather than effectively increasing their income, speculation on contract work serves a compensatory function, providing an important-but ultimately inadequate-sense of control over market conditions that thrive upon workers' economic insecurity.

Sacrificial Labour: Social Inequality, Identity Work, and the Damaging Pursuit of Elusive Futures

This article explores the relationship between personal sacrifice and identity work within conditions of profound structural insecurity. We develop the concept of sacrificial labour to describe how individual self-sacrifice aligns workers' identities to the needs of organizations while gradually foreclosing the actualization of individuals' desired future selves. Drawing upon qualitative data from a longitudinal study of healthy individuals who enrol in paid clinical trials for the pharmaceutical industry, we make two contributions to the identity-work literature. First, we argue that the ongoing project of building stable and secure identities may become damaging when structural and cultural conditions defy even provisional, fragile attainment of this goal. Second, we reflect on how racialization and social marginalization erode identities and constrain possibilities for identity recuperation. Whereas the identity-work literature often focuses on the agential accomplishments of individuals, we provide a troubling account of how persistent social and economic inequalities confound identity realization efforts.

Picking and Choosing Among Phase I Trials : A Qualitative Examination of How Healthy Volunteers Understand Study Risks

This article empirically examines how healthy volunteers evaluate and make sense of the risks of phase I clinical drug trials. This is an ethically important topic because healthy volunteers are exposed to risk but can gain no medical benefit from their trial participation. Based on in-depth qualitative interviews with 178 healthy volunteers enrolled in various clinical trials, we found that participants focus on myriad characteristics of clinical trials when assessing risk and making enrolment decisions. These factors include the short-term and long-term effects; required medical procedures; the type of trial, including its design, therapeutic area of investigation, and dosage of the drug; the amount of compensation; and trust in the research clinic. In making determinations about the study risks, participants rely on information provided during the consent process, their own and others' experiences in clinical trials, and comparisons among studies. Our findings indicate that the informed consent process succeeds in communicating well about certain types of risk information while simultaneously creating lacunae that are problematically filled by participants through their collective experiences and assumptions about risk. We discuss the ethical implications of these findings and make recommendations for improving the consent process in healthy volunteer trials.

Healthy Volunteers' Perceptions of the Benefits of Their Participation in Phase I Clinical Trials

Other than the financial motivations for enrolling in Phase I trials, research on how healthy volunteers perceive the benefits of their trial participation is scant. Using qualitative interviews conducted with 178 U.S. healthy volunteers enrolled in Phase I trials, we investigated how participants described the benefits of their study involvement, including, but not limited to, the financial compensation, and we analyzed how these perceptions varied based on participants' sociodemographic characteristics and clinical trial history. We found that participants detailed economic, societal, and noneconomic personal benefits. We also found differences in participants' perceived benefits based on gender, age, ethnicity, educational attainment, employment status, and number of clinical trials completed. Our study indicates that many healthy volunteers believe they gain more than just the financial compensation when they accept the risks of Phase I participation.

Healthy volunteers' perceptions of risk in US Phase I clinical trials: A mixed-methods study

BACKGROUND

There is limited research on healthy volunteers' perceptions of the risks of Phase I clinical trials. In order to contribute empirically to long-standing ethical concerns about healthy volunteers' involvement in drug development, it is crucial to assess how these participants understand trial risks. The objectives of this study were to investigate (1) participants' views of the overall risks of Phase I trials, (2) their views of the risk of personally being harmed in a trial, and (3) how risk perceptions vary across participants' clinical trial history and sociodemographic characteristics.

METHODS AND FINDINGS

We qualitatively and quantitatively analyzed semi-structured interviews conducted with 178 healthy volunteers who had participated in a diverse range of Phase I trials in the United States. Participants had collective experience in a reported 1,948 Phase I trials (mean = 10.9; median = 5), and they were interviewed as part of a longitudinal study of healthy volunteers' risk perceptions, their trial enrollment decisions, and their routine health behaviors. Participants' qualitative responses were coded, analyzed, and subsequently quantified in order to assess correlations between their risk perceptions and demographics, such as their race/ethnicity, gender, age, educational attainment, employment status, and household income. We found that healthy volunteers often viewed the overall risks of Phase I trials differently than their own personal risk of harm. The majority of our participants thought that Phase I trials were medium, high, or extremely high risk (118 of 178), but most nonetheless felt that they were personally safe from harm (97 of 178). We also found that healthy volunteers in their first year of clinical trial participation, racial and ethnic minority participants, and Hispanic participants tended to view the overall trial risks as high (respectively, Jonckheere-Terpstra, -2.433, p = 0.015; Fisher exact test, p = 0.016; Fisher exact test, p = 0.008), but these groups did not differ in regard to their perceptions of personal risk of harm (respectively, chi-squared, 3.578, p = 0.059; chi-squared, 0.845, p = 0.358; chi-squared, 1.667, p = 0.197). The main limitation of our study comes from quantitatively aggregating data from in-depth interviews, which required the research team to interpret participants' nonstandardized risk narratives.

CONCLUSIONS

Our study demonstrates that healthy volunteers are generally aware of and reflective about Phase I trial risks. The discrepancy in healthy volunteers' views of overall and personal risk sheds light on why healthy volunteers might continue to enroll in clinical trials, even when they view trials on the whole as risky.

Strategies for Obtaining Access to Secretive or Guarded Organizations

Establishing contacts and gaining permission to conduct ethnographic or qualitative research can be time-consuming and stressful processes. Gaining access can be especially challenging when representatives of prospective research sites see their work as being sensitive and would prefer to avoid outside scrutiny altogether. One result of this dynamic is that many organizations that exert a profound influence in governing populations and regulating individuals' access to basic needs are relatively invisible to the public and shielded from meaningful public accountability. Therefore, it is vital to effectively study secretive or guarded organizations and fill out the empirical record, which in turn could create the conditions for greater public awareness and debate. To that end, this paper draws on our collective research experience and the scholarship of others to present nine strategies that we have found to be especially effective for securing access to secretive organizations.

'I'm still a hustler': entrepreneurial responses to precarity by participants in phase I clinical trials

This paper questions the implications of entrepreneurial responses to conditions of employment precarity by 'healthy volunteers' in phase I clinical trials in the United States. Such individuals are typically serial participants who often identify as professional volunteers and seek out drug studies as their primary source of income. Drawing on extensive qualitative research, this paper illustrates how healthy volunteers selectively import the identity of 'hustler' from the street environment and reposition it as connoting a set of valuable creative skills that give them a competitive edge over other participants. An entrepreneurial ethos allows them to view personal sacrifice and exposure to potentially dangerous drugs as smart investments leading to financially stable futures. These discursive moves normalize extractive, and at times dehumanizing, labour relations that offload expenses and risks to workers.

The "biosecuritization" of healthcare delivery: examples of post-9/11 technological imperatives

This paper develops the concept of "biosecuritization" to describe new instantiations of the technological imperative in healthcare. Many discourses and practices surrounding hospitals' new investments in information and communication technologies tend to revolve around security provision. Often times, however, scenarios of extreme and exceptional circumstances are used to justify the implementation of identification and tracking technologies that may be more about managerial control than patient care. Drawing upon qualitative research in 23 U.S. hospitals from 2007 to 2009, our analysis focuses on hospitals' deployment of identification and location technologies that manage patients, track personnel, and generate data in real-time. These systems are framed as aiding in the process of managing supplies and medications for pandemic flu outbreaks, monitoring exposure patterns for infectious diseases, and helping triage or manage the location and condition of patients during mass casualty disasters. We show that in spite of the framing of security and emergency preparedness, these technologies are primarily managerial tools for hospital administrators. Just as systems can be used to track infection vectors, those same systems can be used on a daily basis to monitor the workflow of hospital personnel, including nurses, physicians, and custodial staff, and to discipline or reward according to performance. In other words, the biosecuritization modality of the technological imperative leads to the framing of medical progress as the "rationalization" of organizations through technological monitoring, which is intended to promote accountability and new forms of responsibilization of healthcare workers.

Surveillance as cultural practice

This special section of The Sociological Quarterly explores research on “surveillance as cultural practice,” which indicates an orientation to surveillance that views it as embedded within, brought about by, and generative of social practices in specific cultural contexts. Such an approach is more likely to include elements of popular culture, media, art, and narrative; it is also more likely to try to comprehend people's engagement with surveillance on their own terms, stressing the production of emic over etic forms of knowledge. This introduction sketches some key developments in this area and discusses their implications for the field of “surveillance studies” as a whole.

Benefits of "Observer Effects": Lessons from the Field

This paper responds to the criticism that "observer effects" in ethnographic research necessarily bias and therefore invalidate research findings. Instead of aspiring to distance and detachment, some of the greatest strengths of ethnographic research lie in cultivating close ties with others and collaboratively shaping discourses and practices in the field. Informants' performances - however staged for or influenced by the observer - often reveal profound truths about social and/or cultural phenomena. To make this case, first we mobilize methodological insights from the field of science studies to illustrate the contingency and partiality of all knowledge and to challenge the notion that ethnography is less objective than other research methods. Second, we draw upon our ethnographic projects to illustrate the rich data that can be obtained from "staged performances" by informants. Finally, by detailing a few examples of questionable behavior on the part of informants, we challenge the fallacy that the presence of ethnographers will cause informants to self-censor.

Memantine for cognitive impairment in multiple sclerosis: a randomized placebo-controlled trial

Background: Memantine, an NMDA antagonist, is effective for moderate to severe Alzheimer’s disease.

Objective: Determine whether memantine improves cognitive performance (CP) among subjects with multiple sclerosis (MS) and cognitive impairment (CI).

Methods: This double-blind, randomized, placebo-controlled trial (Clinicaltrials.gov NCT00300716) compared memantine 10 mg twice a day (4 week titration followed by 12 weeks on the highest tolerated dose) with placebo. The primary outcome was the change from baseline to exit on the Paced Auditory Serial Addition Test (PASAT) and the California Verbal Learning Test-II (CVLT-II) Long Delay Free Recall (LDFR). Secondary outcomes included additional neuropsychological tests; self-report measures of quality of life, fatigue, and depression; and family/caregiver reports of subjects’ CI and neuropsychiatric symptoms.

Results: The differences between the groups on the change on the PASAT (placebo—memantine = 0.0 correct responses, 95% CI 3.4, 3.4; p = 0.9) and on CVLT-II LDFR (placebo—memantine =—0.6 words, 95% CI —2.1, 0.8; p = 0.4) as well as on the other cognitive tests were not significant. Subjects on memantine had no serious adverse events (AEs) but had more fatigue and neurological AEs as well as, per family members’ reports, less cognitive improvement and greater neuropsychiatric symptoms than subjects on placebo.

Conclusion: Memantine 10 mg twice a day does not improve CP in subjects with MS, ages 18—65, without major depression, who have subjective cognitive complaints and perform worse than one SD below the mean on the PASAT or on the California Verbal Learning Test-II (total recall or delayed free recall).

Treatment of pyoderma gangrenosum with intravenous immunoglobulin

BACKGROUND

Intravenous immunoglobulin (IVIG) is increasingly being used to treat inflammatory and autoimmune disease.

OBJECTIVES

To elucidate the efficacy of IVIG as an adjunct treatment for pyoderma gangrenosum (PG).

PATIENTS/METHODS

Ten patients with PG were treated with IVIG at Johns Hopkins Department of Dermatology. All patients had severe mutilating and/or refractory disease requiring multi-agent therapy. The charts were reviewed retrospectively.

RESULTS

Seven of the ten patients had clearance of PG lesions in the setting of IVIG and six of these patients maintained efficacy with repeated IVIG treatment. Five patients complained of nausea with treatment, and in one case nausea was severe and intractable. One patient developed an immune reaction requiring diphenhydramine and methylprednisolone and another experienced aseptic meningitis.

CONCLUSIONS

IVIG may be an effective adjuvant in the treatment of PG and has an acceptable side-effect profile. Randomized, placebo-controlled, double-blinded trials are needed to confirm this hypothesis.

Talonavicular coalition. Objective gait analysis

Talonavicular coalitions, a rarely reported fusion between the talus and navicular, are often an incidental radiographic finding that may be asymptomatic or associated with peroneal spasm. The authors present a review of literature and case report based on clinical evaluation and instrumented gait analysis. Specifically, a patient presenting with a bilateral talonavicular coalition was objectively evaluated with kinetic, kinematic, muscle dynamometry, and pedobarographic testing to understand the biomechanical limitations related to this pathology. An excessive passive component of ankle torque, a high first metatarsophangeal joint plantar pressure, and a diminished time in the midstance portion of stance phase were measured and compared to those of healthy individuals.

Is Fitness Reaching Only the Wealthy?

Poor Americans bear a disproportionately large burden of chronic disease, which researchers blame on health habits that wealthier Americans have abandoned. Many researchers are looking for ways to bring the health movement to those who now need it most.

Perceived Exertion: An Old Exercise Tool Finds New Applications

Rating scales of perceived exertion, which rely on an individual's subjective perceptions to determine energy output, may have uses beyond the clinic and laboratory-maybe even in everyday life.

Fitness and Exercise in Advertising: Mining a National Mania

Advertisers are using images of fitness to promote just about every product from cosmetics to candy bars. But these campaigns may increase public acceptance of products that do little to promote health-or that may even harm it.

Should Women Go Easy on Exercise?

Women who have been reading the lay press in recent months may get the idea that exercise is bad for them. But it ain't necessarily so.

Family Exercise Means Relative Fitness

Family members have a lot of power over each other. With a little planning and a commitment to succeed, they can use that power to promote each other's fitness.

Exercise and Depression: Swapping Sweat for Serenity?

Many physicians now prescribe exercise as a safe and effective treatment for depression-though researchers are hard-pressed to explain why it seems to help.

Boardsailing: The Spills Don't Dampen the Thrills

Boardsailors may not get bored, but they do get hurt. However, serious injury is unlikely, and participants can obtain modest fitness benefits.

Wheelchair Athletes Need Special Treatment-But Only for Injuries

Disabled athletes are coming into their own, and they now compete in a wide variety of sports. But the medical community hasn't caught up, especially in research.

From Activity to Eternity

Your chances of living to a ripe old age may be improved with regular exercise-no, make that activity.

Physical Therapy Joins the Fitness Boom

Moving physical therapy out of hospitals and into fitness centers seems to make economic sense. But while patients seem pleased and entrepreneurs are enthusiastic, many medical professionals remain skeptical. For both physicians and their patients, the final judgment will be based on results.

HMOs: Directing the Future of Sports Medicine?

Health maintenance organizations may be the best thing to happen to sports medicine since the fitness boom. Or they may hinder patient care and frustrate physicians. It depends on who is asked.