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Last year, I attended an excellent conference organised by the Birkbeck Counselling Association on ‘An exploration of sexuality and psychoanalytic thinking the in twenty-first century’. It was refr...

Debate continues apace over the appropriateness and efficacy of the Work Capability Assessment (WCA) which is used to decide entitlement to Employment and Support Allowance in the UK. Conflicting and contrasting reports have again been emerging recently as more evidence is amassed, while policy goals are re-visited and real-life experiences reflect widespread distress and hardship. This article is a critical attempt to map out some of the many strands of experiences and concerns on the WCA, as the need for change is pressing.

What is the Transformational Government initiative, enabled by information and communications technology (ICT)? We describe its development, origins and prospects in seeking to join up public services to give simple, seamless, one-off access channels for citizens. We look at its governance and working structures, examining how ICT has been used to move towards common infrastructures and approaches in public services, bringing new potential for holistic service delivery. Finally, we show how transformational government has moved on from e-government, noting some risks that may affect its implementation. We note some particular issues affecting local government throughout the article.

April 2008 sees the 20th anniversary of the introduction of the discretionary Social Fund. With dissatisfaction levels ‘on the ground’ running notably high in the past two years, this may prove an apposite time to reflect on the recent performance of the Fund, in light of continuing disputes about both policy and performance.

In the previous paper in this series, basic mechanisms of electrode related injuries were discussed. In this paper, the discussion begins with some of the clinical aspects of burns. This is followed by a summary of the clinical literature on injuries produced by surface and subdermal electrodes. This clinical literature demonstrates that most electrode burns are related to the presence of high frequency electric fields (RF) created either by an electrosurgical unit or a magnetic resonance imaging (MRI) scanner. A smaller number of lesions are produced by low current, long duration direct current (DC) stimulation and during high current stimulation such as defibrillation. A discussion of the clinical complications from indwelling intracranial electrodes centers on electrodes placed for deep brain stimulation (DBS) that are currently used therapeutically in a wide array of neurologic disorders. The probability of considering a post-implant MRI scan is high and the safety of such scans is the focus ...

Electrodes are the essential elements of clinical neurophysiology both in recording of neural activity and in functional electrical stimulation of the nervous system. Therefore it is important to understand the potential complications of using electrodes. In this paper, the factors that influence the chance of electrode related injury are discussed from a theoretical standpoint. The mechanical factors, especially pressure related injury, are discussed first, followed by a discussion of injury that is of chemical origin such as contact dermatitis. Next, the ways in which electrical currents flowing from electrodes can cause injury including: Joule heating, electroporation, electroconformational denaturation, and excitatory neurotoxicity are discussed. The differential effects of constant current and constant voltage stimulation on tissue heating are examined, as are the effects of the conductivity and geometric structure of the stimulated tissue. Finally, the effects of electrochemical reactions are discussed both in the context of surface and implanted electrodes.

Welfare rights advisers are immersed in the day-to-day detail of advising claimants on their rights under social security law that appears to become more complex each year. This article traces some of those difficult entitlement issues of recent decades. Complexity has resulted both from well-intentioned reform and from cuts packages. The article considers the shifting of administrative responsibilities, marketisation and outsourcing and some likely developments that these may facilitate. Rearranging the architecture of welfare and providing broad-brush reforms emerge as key strategies in simplifying social security. Yet reforms may fail, or bring serious risks, often without sufficient informed debate. The article considers implications for simplifying law and future change.

This article highlights how claims for key, but neglected, benefits are being reframed. There are some simplifications, but the main themes are of increased reliance on telephone contact and on new technology to share data. The article ends with a perhaps surprising conclusion.

BACKGROUND We estimated the relative sensitivity and reliability of scalp EEG, cortical EEG and somatosensory evoked potentials (SSEPs) to detect significant changes during aneurysm surgery. METHODS Two observers independently reviewed data from 18 patients who were monitored with scalp EEG, cortical EEG, and SSEPs to determine which if any modality demonstrated significant changes during 25 different episodes of temporary intracranial vascular occlusion. RESULTS Kappa scores indicating the degree of agreement between the two observers were highest for the cortical strip EEG (κ = 0.92) and the SSEPs (κ = 0.82) and much greater than for the scalp EEG data (κ = −0.07). The cortical strip recordings showed changes more often than either the scalp EEG or SSEP during temporary vascular occlusion. In no case did the scalp EEG change when neither the strip nor SSEP changed. In only 4% of events did the observers feel that the SSEP changed when the strip did not, but in 16% of cases, the strip changed without changes in any of the other modalities. CONCLUSIONS Recording of EEG from strip electrodes placed on the cortical surface detects changes more frequently than either scalp EEG or SSEPs during vascular occlusion. Different observers were more likely to agree on whether the cortical strip EEG changed during vascular occlusion than the other modalities. This argues for the possible advantages of recording from strip electrodes during aneurysm surgery.

To determine the effect of anesthesia, temperature, and stimulus characteristics on the response of upper extremity somatosensory evoked responses (SSEP) to repetitive stimulation.Pairs and trains of electrical stimuli were used to elicit the upper extremity SSEP, and the amplitudes of the N20-P22, N13, and Erb's point potentials produced by each stimulus were measured. The ratio of the amplitude of the response to each stimulus to that produced by the first stimulus in a given train was computed. Recordings were also made directly from the cortical surface in a single patient.There were only minimal effects of anesthesia, temperature, or stimulus characteristics on the amplitude ratios for the N13 and Erb's point potentials. The N20-P22 amplitude ratio demonstrated facilitation with interstimulus intervals in the 20-100 ms range and was markedly reduced with hypothermia. The degree of facilitation was strongly dependent on isoflurane and nitrous oxide concentrations. In response to stimulation with trains of four stimuli, increased amplitudes of the N20-P22 complex were seen maximally with the second response while the third and fourth responses were of lower amplitude.There are strong effects of anesthesia and temperature on the cortical responses to repetitive stimulation of the upper extremity. Speculations on the origin of these effects were made.

Monitoring the vagus nerve and the recurrent laryngeal nerve during surgical procedures may reduce the probability of significant nerve injury. As such, a number of methods to monitor these nerves have been devised including placing electrodes directly into the vocal cords or recording from surface electrodes. In direct comparison, monitoring the identical muscles, bipolar hookwire electrodes displayed approximately one order of magnitude greater amplitude, of both spontaneously occurring and evoked electrical activity than double wire endotracheal tube electrodes. The enhanced sensitivity of the hookwire electrodes, despite the technical difficulties with placement, suggests their use when maximum sensitivity is required.

Background . Electrophysiologic studies during rewarming after deep hypothermic circulatory arrest probe the state of the brain during this critical period and may provide insight into the neurological effects of circulatory arrest and the neurologic outcome. Methods . Electroencephalogram (EEG) and evoked potentials were monitored during rewarming in 109 patients undergoing aortic surgery with hypothermic circulatory arrest. Results . The sequence of neurophysiologic events during rewarming did not mirror the events during cooling. The evoked potentials recovered first followed by EEG burst-suppression and then continuous EEG. The time to recovery of the evoked potentials N20-P22 complex was significantly correlated with the time of circulatory arrest even in patients without postoperative neurologic deficits (r = 0.37, ( p = 0.002). The nasopharyngeal temperatures at which continuous EEG activity and the N20-P22 complex returned were strongly correlated (r = 0.44, p = 0.0002; r=0.41, p = 0.00003) with postoperative neurologic impairment. Specifically, the relative risk for postoperative neurologic impairment increased by a factor of 1.56 (95% CI 1.1 to 2.2) for every degree increase in temperature at which the EEG first became continuous. Conclusions . No trend toward shortened recovery times or improved neurologic outcome was noted with lower temperatures at circulatory arrest, indicating that the process of cooling to electrocerebral silence produced a relatively uniform degree of cerebral protection, independent of the actual nasopharyngeal temperature.

With the recent desperate recession in the UK, and with a general election fast approaching, the pace of change in social welfare law and procedures has spiralled fiercely. The government has tried to anticipate or respond to a vast range of difficulties and events. This article gives some context for a wide-ranging third calendar of benefit changes, published online alongside this edition of Benefits: The Journal of Poverty and Social Justice, which aims to keep readers on top of the many changes in a turbulent year: 2009.

Electromagnetic interference (EMI) is an important factor in producing a low signal-to-noise ratio during neurophysiologic recordings in electronically hostile environments such as the operating room. Using a controlled EMI generating source, both capacitative and inductive mechanisms of EMI were explored. The effects of electrode type, total electrode impedance, electrode impedance imbalance, inter-electrode distance, and electrode dipole orientation were also explored. The results of these studies indicate that although there are substantial differences in impedance between various types of electrodes, these have a significant but small effect on recorded EMI compared to other factor such as the electrode dipole orientation. From a practical perspective, the use of heterogeneous electrode combinations does not necessarily cause an increase in EMI and (after appropriate testing on an individual basis) may increase recording convenience in specialized environment such as the operating room.

The theory behind common and differential mode signals, thermal noise, input voltage and input current noise, 1/f noise, and “popcorn” noise is discussed and the results applied to in vivo and in vitro electrophysiological recordings. Intrinsic noise in EEG and evoked potential paradigms was examined as a function of frequency, total electrode impedance, electrode impedance imbalance, and electrode type. It was demonstrated that electrode impedance may be much less important than other electrode properties in determining intrinsic noise levels. Dramatic increases in intrinsic noise levels below 1 Hz are demonstrated, both with real electrodes and pure resistances. Real electrodes, however, show much more rapid noise increase with decreasing frequency, probably as a result of complex electrochemical processes at the electrode-solution interface. From a practical perspective, although the noise levels in electrodes are much lower than the signal in human EEG, studies pursuing small changes in the E...

Proposed generator sites for the N18 component of the somatosensory evoked potential (SEP) range in location from the medulla to the thalamus. Additional knowledge regarding the generators of the N18 will be important in interpreting the results of intra-operative monitoring during skull base surgery and providing the surgeon more specific information. The goal of this study was to use both intracranial electrical recording and the effects of acute brainstem ischemia in humans to further define the generators of N18. Monopolar electrodes were used to record SEP (after median nerve stimulation) from the brainstem surface in eight patients undergoing posterior fossa surgical procedures. Recordings were made from various locations, from the cervico-medullary junction to the level of the aqueduct of Sylvius. As the electrode moved rostrally on the brainstem surface, the difference in latencies between the scalp N18 potential and the electrode potential approached zero, suggesting an upper pontine-lower midbrain origin of the N18 potential. These findings were supported by the lack of change in the N18 potentials of ten patients with basilar tip aneurysms who experienced marked changes of their N20/P22 potentials during temporary occlusion of the distal basilar artery.

This article considers Pension Service access strategy and ‘the personal touch’, against the spectre of 1984. It builds on an article ‘Changing claims?’ (Patterson, 2003, pp 203-6), which considered claim forms, teleclaims and backroom use of information and communication technology (ICT) links.

Developmentally disabled clients with a concomitant mental illness are often underserved or inappropriately treated because of interorganizational barriers, leading to unnecessary hospitalization and lengthy delays in community placement. To overcome these barriers, agencies responsible for developmental disabilities and mental health services in Spokane County in Washington State developed a collaborative system of care in 1989. An interagency consortium was established to promote coordination of services between the community mental health center, the state hospital, the county human services agency, the state's regional developmental disability service agency, the state institution for the developmentally disabled, and several community agencies serving developmentally disabled persons. Between 1990 and 1992, admissions of developmentally disabled persons to the state hospital were more likely to be appropriate admissions of persons suffering from a mental illness, developmentally disabled clients were discharged more efficiently, and crisis respite services were used in place of hospitalization. In addition, anecdotal reports indicated a reduction of interagency tensions.

In this case an adolescent, minor female presents herself for routine dental care, but is pregnant without parental knowledge. She asks the dentist not to reveal the pregnancy to her parents. Three experts including one attorney, one dental educator with 25 years of private practice experience, and one member of a state psychological association's ethics committee comment on the difficult ethical and legal issues found in this actual case.

Electrodes are the essential elements of clinical neurophysiology both in recording of neural activity and in functional electrical stimulation of the nervous system. Therefore it is important to understand the potential complications of using electrodes. In this paper, the factors that influence the chance of electrode related injury are discussed from a theoretical standpoint. The mechanical factors, especially pressure related injury, are discussed first, followed by a discussion of injury that is of chemical origin such as contact dermatitis. Next, the ways in which electrical currents flowing from electrodes can cause injury including: Joule heating, electroporation, electroconformational denaturation, and excitatory neurotoxicity are discussed. The differential effects of constant current and constant voltage stimulation on tissue heating are examined, as are the effects of the conductivity and geometric structure of the stimulated tissue. Finally, the effects of electrochemical reactions are discussed both in the context of surface and implanted electrodes.

Increased peak inspiratory pressure and bronchospasm during general anesthesia can have many etiologies, including the patient's intrinsic disease and mechanical, chemical, or neurogenic causes. We present a case of bronchospasm induced by direct stimulation of the vagus nerve.

Various mental health disciplines have attempted to bring the significance of relational interaction and dysfunction to the attention of the entire field. Over the past 20 years, these efforts have been initiated and developed both independently and collaboratively, and although progress has been made, results have been incremental and insufficient. The inclusion of the Global Assessment of Relational Functioning (GARF) as an option on Axis IV of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) was a milestone but fell short of recognition as a major disorder on Axis I. This article summarizes and provides a background for the historical efforts that have occurred and suggests possibilities for greater prominence of relational disorders in DSM-V. Renewed interest by coalitions of researchers and practitioners in recent years indicates a positive prognosis for greater acceptance of a classification of couple and family dysfunction in the mental health professions.

Monitoring the vagus nerve and the recurrent laryngeal nerve during surgical procedures may reduce the probability of significant nerve injury. As such, a number of methods to monitor these nerves have been devised including placing electrodes directly into the vocal cords or recording from surface electrodes. In direct comparison, monitoring the identical muscles, bipolar hookwire electrodes displayed approximately one order of magnitude greater amplitude, of both spontaneously occurring and evoked electrical activity than double wire endotracheal tube electrodes. The enhanced sensitivity of the hookwire electrodes, despite the technical difficulties with placement, suggests their use when maximum sensitivity is required.

Background . The available techniques for intravascular gene delivery to the heart are inefficient and not organ-specific. Yet, effective treatment of heart failure will likely require transgene expression by the majority of cardiac myocytes. To address this problem, we developed a novel cannulation technique that achieves efficient isolation of the heart in situ using separate cardiopulmonary bypass (CPB) circuits for the heart and body in dogs. Methods . The arterial inflow and venous effluent from the two circuits were physically isolated. The efficiency of separation was 98% to 99% in three preliminary experiments using Evans Blue dye-labeled albumin. In 6 dogs, the cardiac circuit was perfused with oxygenated crystalloid cardioplegia at 37°C containing ≅ 4 × 10 11 particles of an adenovirus encoding LacZ (AdCMVLacZ) with a perfusion pressure of 170 to 200 mm Hg for 15 minutes allowing virus to recirculate through the heart ≅ 15 times. Cross-clamp time was 26 ± 2 minutes and CPB time was 90 ± 3 minutes. Results . Five animals survived and were euthanized at 7 days. β-Galactosidase activities measured using a chemiluminescent assay were three orders of magnitude higher in all areas of the heart than in the liver. Histological analyses revealed heterogeneous X-Gal staining of myocytes in all areas of the myocardium. Conclusions . Despite using a constitutive promoter, this technique yields relatively cardiac-specific transgene expression and is potentially translatable to clinical applications. Future studies will allow for further optimization of the conditions necessary for vector-mediated gene delivery to the heart.

Hypothermia is used clinically to prevent neurologic injury but the degree of protection which it affords at various levels of the nervous system in humans is difficult to establish.The temporal changes in EEG amplitude and somatosensory evoked potential (SEP) amplitudes in a patient experiencing acute normothermic hypoxemia, a patient experiencing acute circulatory arrest at moderate hypothermia and a collection of patients undergoing deep hypothermic circulatory arrest were analyzed to determine the rate at which changes occur during acute lack of oxygen delivery at various temperatures.In each case, it was found that more rostrally generated potentials disappeared more quickly than more peripheral potentials. All potentials decayed more slowly during acute normothermic hypoxemia than during circulatory arrest. During circulatory arrest at 14.4 degrees C, the amplitude of the Erb's point, N13 and N18 potentials in the SEP took 5 times longer to drop to 50% of their value at the onset of ischemia than with circulatory arrest at 30.9 degrees C.The longer times to disappearance of the SEP potentials during deep hypothermia compared to moderate hypothermia was consistent with the predicted 3.5-6.5 fold reduction in metabolic activity at deep hypothermia compared to moderate hypothermia. The prolonged time to disappearance of the SEP during normothermic hypoxemia demonstrates that even with reduced oxygen delivery the continued delivery of metabolic substrate can be critical to neural function.

Deep hypothermia is an important cerebral protectant and is critical in procedures requiring circulatory arrest. The purpose of this study was to determine the factors that influence the neurophysiologic changes during cooling before circulatory arrest, in particular the occurrence of electrocerebral silence.In 109 patients undergoing hypothermic circulatory arrest with neurophysiologic monitoring, five electrophysiologic events were selected for detailed study.The mean nasopharyngeal temperature when periodic complexes appeared in the electroencephalogram after cooling was 29.6 degrees C +/- 3 degrees C, electroencephalogram burst-suppression appeared at 24.4 degrees C +/- 4 degrees C, and electrocerebral silence appeared at 17.8 degrees C +/- 4 degrees C. The N20-P22 complex of the somatosensory evoked response disappeared at 21.4 degrees C +/- 4 degrees C, and the somatosensory evoked response N13 wave disappeared at 17.3 degrees C +/- 4 degrees C. The temperatures of these various events were not significantly affected by any patient-specific or surgical variables, although the time to cool to electrocerebral silence was prolonged by high hemoglobin concentrations, low arterial partial pressure of carbon dioxide, and by slow cooling rates. Only 60% of patients demonstrated electrocerebral silence by either a nasopharyngeal temperature of 18 degrees C or a cooling time of 30 minutes.With the high degree of interpatient variability in these neurophysiologic measures, the only absolute predictors of electrocerebral silence were nasopharyngeal temperature below 12.5 degrees C and cooling longer than 50 minutes.

Objective: The results of neurophysiologic monitoring using somatosensory evoked potentials (SSEPs) and electroencephalography (EEG) were analyzed to determine if retrograde cerebral perfusion (RCP) supported central nervous system electrical function during surgery that required temporary interruption of antegrade cerebral perfusion (IACP). Design: A prospective, observational study. Setting: A university hospital. Participants: Fifteen adult patients who underwent aortic reconstruction using RCP and three patients who underwent thoracic aortic operations using hypothermic circulatory arrest without RCP. Interventions: SSEPs and EEG were monitored continuously throughout the operation. Regression analysis was performed to determine the factors that affected the rate of decrease in SSEP amplitudes during IACP and the time required for SSEP and EEG activity to recover after antegrade cerebral perfusion (ACP) was restored. Measurements and Main Results: The amplitude of SSEPs that were elicited decreased over time after IACP The mean ± standard deviation (SD) time required for the brachial plexus (Erb's point), cervicomedullary junction (N13), and brainstem (N18) SSEPs to decrease to 0.5 of their original amplitude after IACP were 30 ± 2, 19 ± 2, and 16 ± 2 minutes, respectively. The rate of decrease in the N18 SSEP amplitude after IACP correlated positively to the fraction of no-flow time (p = 0.01). Conclusion: RCP attenuated the rate of decay in SSEP amplitudes during IACP. This suggested that RCP had a measurable physiologic effect on central nervous system function and may increase the time that ACP can be safely interrupted.

Electrical interference at mains power supply frequency can adversely affect the recording of evoked potentials and can be especially destructive in an operating room setting. We investigated 60 Hz interference in electrode cables running from subject to preamplifier and further examined methods to eliminate such interference. We conclude that braiding electrode wires is highly efficacious in such interference reduction, presumably by reducing the magnetic flux enclosed by the wires. We further indicate that the use of flexible metal hose fabricated from Permalloy 80 may effect further interference reduction.

Study Design. This case report details intraoperative evoked potential changes during surgical removal of a T8 dural arteriovenous malformation. Objectives. The pattern of changes in somatosensory-evoked responses during surgical correction of a spinal dural arteriovenous malformation can illuminate the pathophysiologic process behind the clinical symptoms. Summary of Background Data. Arteriovenous malformation of the spinal dura can manifest with multiple symptoms, including progressive myelopathy and pain. The pathophysiologic process behind these symptoms could be either direct compression of the spinal cord by the arteriovenous malformation, ischemia resulting from shunting of the blood flow away from the cord, or increased venous pressure. Methods. To investigate these hypotheses further, the results of posterior tibial evoked potentials obtained during surgical removal of a T8 dural arteriovenous malformation were analyzed. Results. At baseline, the cortical (P40) potential was markedly prolonged bilaterally. During surgery, just after the dura was opened, a marked increase was observed in the latencies of the P40 and P60 components of the evoked response on the right, which began to resolve as soon as the arteriovenous malformation was occluded. Only minimal changes were seen on the left. Conclusions. These results are most consistent with the increased venous pressure hypothesis for the pathogenesis of neurologic symptoms in dural arteriovenous malformations.

Cholinergic blocking with scopolamine produces skin conductance orientating response (SCOR) nonresponding in normal subjects. This may be one of a number of causes for nonresponding in schizophrenic subjects. Blockade of dopamine with haloperidol produces an increase in amplitude and shortening of recovery time in the SCOR of normal subjects. This result closely resembles that of Nielsen and Petersen (1976) who found a similar pattern of responding in normal subjects who scored high on a scale of schizophrenism. These results, along with those for chlorpromazine and the pupillographic effects of the three drugs are discussed in terms of biochemical working hypotheses of schizophrenic subclassification.

A general introduction is given and followed by a review of recent literature under the following subheadings: electrodermal activity, cardiovascular activity, smooth pursuit eye movement, electroencephalogram, and evoked potentials. An attempt is made to assess the clinical significance of the findings reported in each area and to indicate directions for future investigation. The feasibility of defining homogeneous subgroups in schizophrenia using psychophysiological parameters is also considered. The review concludes with the recommendation that peripheral psychophysiological studies entailing (1) comprehensive recording of brain electrical activity and (2) behavioral experimentation on variables thought to be influenced by schizophrenia (e.g., sustained attentional ability) are promising directions for future research. Relationships between behavioral and psychophysiological variables determined by such studies (and possibly subgroupings) may then become the basis for neurophysiological-neurochemical investigations of specific abnormalities underlying such relationships and subgroups.