Directional deep brain stimulation contacts provide greater spatial flexibility for therapy than traditional ring-shaped electrodes, but little is known about longitudinal changes of impedance and orientation. We measured monopolar and bipolar impedance of DBS contacts in 31 patients who underwent unilateral subthalamic nucleus deep brain stimulation as part of a randomized study. At different follow-up visits, patients were assigned new stimulation configurations and impedance was measured. Additionally, we measured the orientation of the directional lead during surgery, immediately after surgery, and (...) 1 year later. Here we contrast impedances in directional versus ring contacts with respect to local anatomy, active stimulation contact, and over time. Directional contacts display larger impedances than ring contacts. Impedances generally increase slightly over the first year of therapy, save for a transient decrease immediately post-surgery under general anesthesia during pulse generator placement. Local impedances decrease at active stimulation sites, and contacts in closest proximity to internal capsule display higher impedances than other anatomic sites. DBS leads rotate slightly in the immediate postoperative period but otherwise remain stable over the following year. These data provide useful information for setting clinical stimulation parameters over time. (shrink)

Introduction: Although deep brain stimulation often improves levodopa-responsive gait symptoms, robust therapies for gait dysfunction from Parkinson's disease remain a major unmet need. Walking speed could represent a simple, integrated tool to assess DBS efficacy but is often not examined systematically or quantitatively during DBS programming. Here we investigate the reliability and functional significance of changes in gait by directional DBS in the subthalamic nucleus.Methods: Nineteen patients underwent unilateral subthalamic nucleus DBS surgery with an eight-contact directional lead in the most (...) severely affected hemisphere. They arrived off dopaminergic medications >12 h preoperatively and for device activation 1 month after surgery. We measured a comfortable walking speed using an instrumented walkway with DBS off and at each of 10 stimulation configurations at the midpoint of the therapeutic window. Repeated measures of ANOVA contrasted preoperative vs. maximum and minimum walking speeds across DBS configurations during device activation. Intraclass correlation coefficients examined walking speed reliability across the four trials within each DBS configuration. We also investigated whether changes in walking speed related to modification of step length vs. cadence with a one-sample t-test.Results: Mean comfortable walking speed improved significantly with DBS on vs. both DBS off and minimum speeds with DBS on. Pairwise comparisons showed no significant difference between DBS off and minimum comfortable walking speed with DBS on. Intraclass correlations were ≥0.949 within each condition. Changes in comfortable walk speed were conferred primarily by changes in step length.Conclusion: Acute assessment of walking speed is a reliable, clinically meaningful measure of gait function during DBS activation. Directional and circular unilateral subthalamic DBS in appropriate configurations elicit acute and clinically significant improvements in gait dysfunction related to PD. Next-generation directional DBS technologies have significant potential to enhance gait by individually tailoring stimulation parameters to optimize efficacy. (shrink)

At Moore’s time, the main-stream ethical theory is the doctrine that pleasure alone is good as an end as held by the hedonistic utilitarianism. Moore, however, asserts that good, not composed of any parts, is a simple notion and indefinable, and naturalistic ethical theories, in particular hedonistic utilitarianism, interpret intrinsic good as a property of a single natural object---pleasure, which is also the sole end of life, thus violates naturalistic fallacy. Moore seems to believe that there exist things other than (...) pleasure that are also intrinsically good and has searched for them. But Moore has not clearly stated what these things are, nor has he given any justification for why they are intrinsically good. This paper discusses Moore’s arguments and difficulties of utilitarianism. With the subjectivistic utilitarian theory of value, Unified Utilitarian Theory (UTT) discards the classification of value into intrinsic and instrumental and proves to be exempt of all theexisting difficulties with utilitarianism related to pleasure, including naturalistic fallacy, vagueness of pleasure and sole end of life, double counting, etc. (shrink)

This paper argues that the notion of value has been overly simplified and narrowed to focus on economic returns. Stakeholder theory provides an appropriate lens for considering a more complex perspective of the value that stakeholders seek as well as new ways to measure it. We develop a four-factor perspective for defining value that includes, but extends beyond, the economic value stakeholders seek. To highlight its distinctiveness, we compare this perspective to three other popular performance perspectives. Recommendations are made regarding (...) performance measurement for both academic researchers and practitioners. The stakeholder perspective on value offered in this paper draws attention to those factors that are most closely associated with building more value for stakeholders, and in so doing, allows academics to better measure it and enhances managerial ability to create it. (shrink)

Legal battles continue in the UK over the Government’s plans to transport asylum seekers arriving on British shores to Rwanda in East Africa. Originally announced as a system for ‘processing’ asylum seekers, the Government has subsequently made it clear that there would not be an option for asylum seekers to return to the UK. The arrangement forms part of a deal between the UK and Rwanda, with the UK promising to invest £120 m in economic growth and development in Rwanda, (...) along with financing the cost of the ‘offshored’ asylum operation.1 The Government states that the policy is designed to break the business model of people traffickers involved in facilitating hazardous trips across the Channel in small, overcrowded and unseaworthy craft, leading to multiple drownings. Critics argue that the policy will do nothing to stop desperate people from seeking refuge in the UK, that transferring already traumatised people to Rwanda – which has been criticised for its human rights record – is inhumane and potentially outwith international law. Medical bodies, including the BMA, along with refugee organisations have expressed serious concerns about the health impact of such a system of ‘offshoring’. An equivalent system in Australia has been notorious for the devastating health impacts on those ‘offshored’ to the Pacific islands of Manus and Naura. Unusually in the UK the offshoring proposals have been greeted by unanimous condemnation by the Church of England. The lawfulness of the process is also subject to question. On the 14 July, a plane carrying a small number of asylum seekers to Rwanda was halted shortly before take-off following an intervention by the European Court of Human Rights. The ECtHR, part of the Council of Europe, of which the UK is still a member, said an Iraqi man known as KN faced ‘a real …. (shrink)

Stakeholder theory focuses on how more value is created if stakeholder relationships are governed by ethical principles such as integrity, respect, fairness, generosity and inclusiveness. However, it has not adequately addressed strategies that stakeholders perceive as harmful to their interests and how this perception can even lead some stakeholders to view the firm’s strategies as unethical. To fill the void, this paper directly addresses strategies that stakeholders perceive as harmful to their interests, or what we refer to as harmful stakeholder (...) strategies. Specifically, it identifies factors associated with stakeholder perceptions of harm that are likely to cause them to consider a strategy unethical, examines the negative implications for firms that pursue such strategies in terms of likely stakeholder responses and damage to stakeholder relationships, and provides theory to help explain how firms are likely to respond to stakeholder claims that a strategy is unethical, based on factors such as the strategic importance of the claim to the firm, how long the strategy has been in use, the costs of remediation, the risk of stakeholder mobilization or new regulation, and whether firms can reasonably rationalize their actions. Assessing harm allows a firm to make a more accurate estimate of the costs of a strategy and can assist managers in allocating resources intended to reduce or remediate harm. (shrink)

In previous Ethics briefings 1 we have highlighted the developments in the case of Bell & Another v the Tavistock and Portman NHS Foundation Trust. The case concerned a judicial review of the practice of prescribing puberty blocking treatment to children and young people at the Gender Identity Development Service managed by the Tavistock and Portman NHS Foundation Trust. The Court of Appeal in its judgement2 found the Trust’s practices to be lawful, and overturned previous guidance given by the High (...) Court which had contradicted the 'Gillick principle' regarding whether a child or young person could consent to medical treatment, without the consent of its parent. Despite this legal success, concerns over the GIDS continued. In September, NHS England commissioned an independent and wide-ranging review of gender identity services for children and young people led by Dr Hilary Cass, past president of the Royal College of Paediatrics and Child Health. Dr Cass’s Interim review, published in March,3 has resulted in a decision by NHS England to close the GIDS at the Trust by Spring 2023, and replace it with regional centres at existing children’s hospitals offering more 'holistic care' with ’strong links to mental health services’. It is proposed that regional centres will be established at Great Ormond Street Hospital, and Alder Hey Children’s NHS Foundation Trust. Dr Cass was critical of the clinic’s failure to collect sufficient data on the impact of puberty blockers in under-16s. …. (shrink)

The office of the United nations high commissioner for human rights (OHCHR): serious human rights abuses against the Uyghur people in Xinjiang, China Very close to midnight on the 31 August 2022, minutes before Michelle Bachelet’s four-year term as UN Commissioner for Human Rights came to an end, her office finally succeeded in publishing her long-delayed report into serious human rights violations in the Xinjiang province in China. According to The Guardian newspaper, papers leaked in July of the same year (...) showed sustained efforts by China to prevent the report’s release, and Bachelet has subsequently spoken of the intense pressure she was put under by the Chinese to prevent the report’s publication. 1 The report is sobering. 2 It is explicit that the Peoples’ Republic of China (PRC) has committed systematic violations of fundamental human rights against the Uyghur and other Turkic Muslim minorities in Xinjiang... (shrink)

BackgroundStructured, systematic methods to formulate consensus recommendations, such as the Delphi process or nominal group technique, among others, provide the opportunity to harness the knowledge of experts to support clinical decision making in areas of uncertainty. They are widely used in biomedical research, in particular where disease characteristics or resource limitations mean that high-quality evidence generation is difficult. However, poor reporting of methods used to reach a consensus – for example, not clearly explaining the definition of consensus, or not stating (...) how consensus group panellists were selected – can potentially undermine confidence in this type of research and hinder reproducibility. Our objective is therefore to systematically develop a reporting guideline to help the biomedical research and clinical practice community describe the methods or techniques used to reach consensus in a complete, transparent, and consistent manner.MethodsThe ACCORD project will take place in five stages and follow the EQUATOR Network guidance for the development of reporting guidelines. In Stage 1, a multidisciplinary Steering Committee has been established to lead and coordinate the guideline development process. In Stage 2, a systematic literature review will identify evidence on the quality of the reporting of consensus methodology, to obtain potential items for a reporting checklist. In Stage 3, Delphi methodology will be used to reach consensus regarding the checklist items, first among the Steering Committee, and then among a broader Delphi panel comprising participants with a range of expertise, including patient representatives. In Stage 4, the reporting guideline will be finalised in a consensus meeting, along with the production of an Explanation and Elaboration document. In Stage 5, we plan to publish the reporting guideline and E&E document in open-access journals, supported by presentations at appropriate events. Dissemination of the reporting guideline, including a website linked to social media channels, is crucial for the document to be implemented in practice.DiscussionThe ACCORD reporting guideline will provide a set of minimum items that should be reported about methods used to achieve consensus, including approaches ranging from simple unstructured opinion gatherings to highly structured processes. (shrink)

Originally published in 1954, this is the first full-length account of the history of the Working Men’s College in St.Pancras, London. One hundred and fifty years on from its foundation in 1854, it is the oldest adult educational institute in the country. Self-governing and self-financing, it is a rich part of London’s social history. The college stands out as a distinctive monument of the voluntary social service founded by the Victorians, unchanged in all its essentials yet adapting itself to the (...) demands of each generation of students and finding voluntary and unpaid teachers to continue its tradition. (shrink)

Originally published in 1954, this is the first full-length account of the history of the Working Men’s College in St.Pancras, London. One hundred and fifty years on from its foundation in 1854, it is the oldest adult educational institute in the country. Self-governing and self-financing, it is a rich part of London’s social history. The college stands out as a distinctive monument of the voluntary social service founded by the Victorians, unchanged in all its essentials yet adapting itself to the (...) demands of each generation of students and finding voluntary and unpaid teachers to continue its tradition. (shrink)

Savage et al. and Mehr et al. provide well-substantiated arguments that the evolution of musicality was shaped by adaptive functions of social bonding and credible signalling. However, they are too quick to dismiss byproduct explanations of music evolution, and to present their theories as complete unitary accounts of the phenomenon.

A collection of five essays in which the religious experiences and activities of individuals, communities, and cultures are seen as preeminently rational responses to reality. Of interest to students and scholars of technology and philosophy.