Zeitschriftenartikel zum Thema „Herman@s (Association)“

The Centre des livres d’artistes (cdla), which has been based in S aint-Yrieix-la-Perche since 1994, is the culmination of a project initiated at the end of the 1980s by the association Pays-paysage. After many years during which it lacked anywhere to develop its activities fully, the cdla has at last been installed in a refurbished building and opened early in 2005 with a new exhibition of books and publications by herman de vries. The two principal activities of the cdla are the creation and management of a collection of artists’ books (currently nearly 3000 items), and the organisation of exhibitions in France and also abroad.

Cisolok Village is a village with a geographical location bordering the Indonesian Ocean. It has the potential for marine tourism and supporting MSMEs. The digital marketing branding seminar with the theme of optimizing social media in introducing local products digitally is one of the efforts made in Community Service activities to be able to increase the insight of Cisolok Village MSME players to recognize digital marketing branding in the hope of increasing product recognition to the wider community and increasing sales profits. The Cisolok Village digital marketing branding seminar was held on Tuesday, August 08, 2023 at the Cisolok Village Office Hall with presenters Imelda D.S SE (Mother of UMKM Sukabumi), Herman Subandi S,Ip M.Si (DKUKM representative), and Rosita Juliyanti, S.I.Kom (online import clothing entrepreneur). The seminar was attended by participants from the Sukabumi UMKM association in Cisolok Village, as well as village officials, hamlet heads, neighborhood heads, PKK cadres and Posyandu cadres. Digital marketing branding is important for UMKM players because it can more easily promote their businesses due to wider reach, more efficient costs, direct interaction online (cyberspace) with consumers, and also the ease for entrepreneurs in choosing specific targets or potential customers according to the criteria of the business being undertaken.

Abstract Selpercatinib (LOXO-292, LY3527723) and pralsetinib (BLU-667) are first-in-class RET-targeted cancer therapy drugs. However, secondary RET mutations that confer selpercatinib/pralsetinib resistance have been identified, necessitating development of next-generation RET Tyrosine kinase inhibitors (TKIs). While the G810C/R/S/V mutations located at the RET kinase solvent-front site were detected in selpercatinib-treated patients, it was unclear whether all of these and other potential G810 mutants are resistant to selpercatinib and pralsetinib. We profiled selpercatinib and pralsetinib on all six possible G810 mutants derived from single nucleotide substitution. Surprisingly, the G810V mutant found in a clinical study was not resistant to selpercatinib or pralsetinib. Besides G810C/R/S, G810D also conferred selpercatinib/pralsetinib resistance. We found that alkynyl nicotinamide compounds such as HSN608 have better drug-like properties than alkynyl benzamides. HSN608 inhibited RET and RET V804M gatekeeper mutant, and all six G810 mutants with low nanomolar IC50s in the BaF3/KIF5B-RET mutant cell model. In cell derived xenograft (CDX) tumors driven by KIF5B-RET(G810C), HSN608 caused regression of the selpercatinib-resistant tumors. This study clarifies the sensitivities of different RET solvent-front mutants to selpercatinib and pralsetinib, and identifies an alkylnyl nicotinamide-based RET TKI for inhibiting selpercatinib/pralsetinib-resistant G810 mutants. Citation Format: Ujjwol Khatri, Neetu Dayal, Xueqing Hu, Elizabeth Larocque, Nimishetti Naganna, Tao Shen, Xuan Liu, Frederick W. Holtsberg, M. Javad Aman, Herman O. Sintim, Jie Wu. Targeting RET solvent-front mutants with an alkynyl nicotinamide-based inhibitor. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3851.

Abstract Rearranged during transfection (RET) is a protein tyrosine kinase that is aberrantly activated by gene fusions or mutations in many types of human cancer including thyroid cancer and non-small cell lung cancer (NSCLC). Selpercatinib (LOXO-292) and pralsetinib (BLU-667) are FDA approved RET-selective tyrosine kinase inhibitors (TKIs) being used to treat RET-altered cancer. However, these tumors develop selpercatinib/pralsetinib-resistance via acquisition of RET(G810C/R/S) mutations located at the solvent front of the ATP binding pocket. The overall goal of our research is to discover next-generation of RET kinase inhibitors to inhibit selpercatinib/pralsetinib-resistant RET solvent-front mutants. In this study, we characterized one of the nicotinamide-based RET kinase inhibitor, HSN748, in vitro and in vivo. HSN748 was able to inhibit selpercatinib/pralsetinib-resistant RET(G810C/R) solvent-front mutations. In BaF3/KIF5B-RET(G810C) tumor xenograft experiment, HSN748 treatment resulted in tumor regression. In immune competent transgenic mice, KIF5B-RET-induced lung tumors regressed after HSN748 treatment by oral gavage for one month (10-15 mg/kg, QD) without affecting body weight. These results identify HSN748 as an orally available RET inhibitor capable of inhibiting KIF5B-RET and its solvent-front mutant-driven tumors. Citation Format: Ujjwol Khatri, Neetu Dayal, Tao Shen, Xueqing Hu, Herman Sintim, Jie Wu. Characterization of a nicotinamide-based kinase inhibitor HSN748 for inhibition of RET-driven tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4660.

Abstract Introduction: Identification of human subjects who qualify for a cancer trial can be challenging, particularly given narrow time frames for enrollment and highly specific criteria for eligibility. We sought to identify patients on a timely basis by matching trial criteria to data present in both the Pathology and clinical information systems. In a separate abstract submitted to the AACR meeting, we described the enrollment outcomes of our effort for two clinical trials. In this companion abstract, we describe the query methods that we employed. Methods: Method #1 involved querying structured data fields in the EMR, using dashboards or SQL queries of relational databases. Method #2 utilized natural language processing (NLP) queries of narrative text in pathology reports. We assessed the useability of each query approach, on a near-real-time basis, against eligibility criteria for open clinical trials at our institution. Results: We examined the first 25 open clinical trials for treatment of solid tumors listed publicly on our institutional website. For each trial, eligibility and query criteria were compiled by two reviewers (DC,YZ); discrepancies between reviewers were resolved by a third reviewer (NY). We found that of the 33 trials examined: 26 trials (79%) could be successfully analyzed by NLP in the pathology report. 2 trials (6%) required SQL query of discrete data fields in clinical databases. 2 trials (6%) required both methods to be used together. 3 trials (9%) required data elements outside the scope of either method. The data fields provided by NLP were: tumor morphology; tumor stage; specimen margin; and tumor receptor status. The data fields provided by SQL were: ICD 10 codes, CPT codes, Chemotherapy, and quantitative lab results. The data fields not accessible by either approach were: tumor resectability and risk calculation. Conclusion: There is no single method that is best for all trials, and availability of a broad set of tools is needed to craft a fitting query for each trial. However, 26 of 33 trials (79%) required NLP to parse eligibility criteria from narrative pathology reports. Cancer clinical trials enrollment may be substantially enhanced by NLP extraction of structured data from pathology reports as part of a near-real-time workflow for identifying eligible Human Subjects. Citation Format: Nalan Yurtsever, Yonah Ziemba, Daniel A. King, Dylan J. Cooper, Sergio Garza, Cheryl B. Schleicher, Sharon S. Fox, James M. Crawford, Joseph Herman. The need for structured pathology data in matching human subjects to cancer clinical trial criteria: A methodological approach [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3167.

Abstract The purpose of this study was to improve the identification and solicitation of human subject candidates to augment patient enrollment to clinical trials. In the past, our enrollment efforts involved manual mechanisms that began at the time that cancer patients were presented for care, most commonly at our chemotherapy clinics. We reasoned that computational review of pathology records may be far more efficient, allowing us to screen larger numbers of patients, and may allow us to intercept patients at the time of diagnosis, rather than time of care. We thus implemented a new workflow: (1) computational query of pathology database to filter candidates based on key eligibility criteria; (2) validation of the query using a clinical research coordinator, who can then (3) navigate the patient to the trial. As a proof of concept, starting in August of 2022, we selected two gastrointestinal oncology trials, the COBRA and PACES trial, based on trial eligibility that could be easily extracted using pathologic criteria, and because these trials had low enrollment. We designed computational queries to extract cohorts of potential patients whose surgery dates and pathology staging identified potential clinical trial candidates. A coordinator performed chart-review to validate these candidates. The trial coordinator then contacted the patient’s surgical oncologist, facilitated referral to a medical oncologist, and tracked the number of patients approached and consented. Whereas in a 12-month period preceding this new workflow, we had 0 and 1 patients approached for the PACES and COBRA trial, in the 3-month period following the new intervention, we had 8 and 2 patients approached. These data suggest computational cohort building and subsequent navigation have the potential to improve enrollment onto clinical trials and motivate extension of this work to additional trials. Table(s) Trial # of patients approached pre-intervention Computational Criteria Meeting computational criteria Coordinator validation criteria # of patients validated by coordinator # of patients connected with medical oncologist # of patients approached post-intervention PACES 0 Colorectal cancer, stage T0-T3,N0-1 Date Aug 2021 – July 2022 23 Facility location, No evidence of disease on colonoscopy performed 120 -456 days post-surgery, No chemotherapy, No other malignancy 18 8 8 COBRA 1 Colorectal cancer pT3N0resection date August 2022 – October 2022 18 ≥ 12 lymph nodes assessedPatient locationIf the subject appropriate for active surveillanceSurgery within 14-60 days of randomization 4 0 2 Citation Format: Yonah Ziemba, Kaitlin Parnahay, Paul Ward, Nalan Yurtsever, Sharon Fox, Cheryl Schleicher, Priya Singh-Shiwsankar, Vincent Vinciguerra, Joseph Herman, James M. Crawford, Daniel A. King. Computational cohort discovery and coordinator-led validation to navigate potential research candidates to clinical trials [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3150.

Abstract Osteosarcoma (OS) is an aggressive pediatric solid tumor that is difficult to treat with established therapies. We performed CRISPR/Cas9 screening in 13 OS cell lines as part of the Dependency Map project. Mining this data to identify genes whose knockout (KO) leads to selective anti-viability in OS, we observed the helicase SMARCAL1 as a selective dependency in OS (p<0.0001; effect size = -0.275). Given the genomic instability of OS and SMARCAL1’s related, established role in replication stress, we first validated our screens by CRISPR KO in OS lines in vitro. This demonstrated selective antiviability of SMARCAL1 KO in dependent OS lines. To orthogonally validate SMARCAL1 dependency, we deployed a dTAG system, utilizing a hetero-bifunctional small molecule targeting the tagged protein for degradation by an E3 ubiquitin ligase. We observed antiviability of dependent lines after SMARCAL1 degradation. In parallel, in order to ascertain importance of this gene in vivo, we performed a barcoded CRISPR pooled screen against pre-selected OS dependencies in an OS cell line xenograft in NSG mice. After sequencing of tumor gDNA, we identified SMARCAL1 as a top hit, suggesting relevance in vivo.We next investigated biomarkers of SMARCAL1 dependency. A role for SMARCAL1 has been described in alternative lengthening of telomeres (ALT). We asked whether ALT+ OS cell lines are enriched for SMARCAL1 dependency. We found a correlation between ALT+ OS and SMARCAL1 dependence in our CRISPR screens. We then asked if this extends to other ALT+ tumors. Neuroblastoma (NB), the most common extracranial pediatric solid tumor, is enriched for ALT. When we looked specifically at NB models, we observed that SMARCAL1 was the most enriched dependency in ALT+ NB compared with other NB lines (p<0.0001; effect size = -0.785). We then performed SMARCAL1 KO in 2 ALT+ ATRX-altered NB lines and one ALT+ ATRX-WT NB line. We found that SMARCAL1 KO led to antiviability in the ATRX-altered ALT+ cell lines, while the ALT+ ATRX-WT cell line was unaffected. This suggests that dependency on SMARCAL1 is specific to ATRX alteration, rather than ALT alone.In order to confirm synthetic lethality between ATRX and SMARCAL1, we next utilized a human OS line not included in the DepMap screen, which has biallelic inactivation of SMARCAL1. We infected this line with our SMARCAL1 dTAG, leading to constitutive overexpression of SMARCAL1, and then performed ATRX KO. We observed that SMARCAL1 overexpression rescued the antiviability effect of ATRX KO. This could be reversed by degradation of exogenous SMARCAL1, suggesting that ATRX and SMARCAL1 can compensate for one another. Taken together, these findings demonstrate that SMARCAL1 is a selective dependency engendered by the loss of WT ATRX in OS and NB and that SMARCAL1 is playing a critical role in mediating ALT. Studies are ongoing to determine the mechanism of SMARCAL1’s activity and potential for targeting this enzyme for therapeutic benefit. Citation Format: Monika Wierdl, Jerrel L. Catlett, Nicole Ocasio-Martinez, Jon D. Johnson, Amy Herman, Neekesh V. Dharia, Gabriela Alexe, E. Alejandro Sweet-Cordero, Emily Bernstein, Kimberly Stegmaier, Lillian M. Guenther. SMARCAL1 is a novel synthetic lethal target in ALT+ osteosarcoma and neuroblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3949.

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Abstract Introduction: Emergence of resistance to immune checkpoint blockade (ICB) mandates the development of strategies for ICB sensitization. Here we employed a multi-omic approach to understand the effects of epigenetic priming in re-shaping the tumor microenvironment, together with genomic drivers of therapeutic response of epigenetic therapy followed by ICB in non-small cell lung cancer (NSCLC). Methods: We performed whole exome sequencing (WES) on 39 baseline tumors and bulk RNA sequencing (RNAseq) on 18 serial tumors across 42 patients with metastatic immunotherapy-naïve NSCLC, who received azacitidine and entinostat followed by nivolumab (NCT01928576). WES was utilized to assess co-mutations, mutation signatures and genome-wide structural changes. RNAseq was utilized for gene and gene set enrichment analysis (GSEA) and repeat element analysis. Response after nivolumab initiation was assessed using RECIST 1.1 criteria. Patients who were progression-free at 6 months or alive at 2 years after initial treatment were defined as exceptional responders. Results: We found an enrichment in inactivating mutations in homologous recombination genes in radiographic responders (Fisher’s exact, p=0.0007). Higher germline and somatic HLA class II diversity (Mann-Whitney U-test, p=0.05 and p=0.03 respectively), and an enrichment of smoking and DNA damage mutational signatures were noted in radiographic responders (Mann-Whitney U-test, p=0.03 and p=0.15 respectively). Radiographically responding tumors harbored a higher number of mutations in genomic regions that were haploid or present in multiple copies (persistent tumor mutation burden; Mann-Whitney U-test, p=0.018). GSEA revealed an upregulation of inflammatory response gene sets post-epigenetic therapy in patients attaining an exceptional response. Antigen presentation, interferon-alpha, and interferon-gamma related gene sets were upregulated in exceptional responders post epigenetic priming (FDR-adjusted p=0.005, p=0.009, and p=0.011 respectively). Additionally, we observed an enrichment in interferon-alpha, cancer testis antigens, and interferon-gamma related gene sets in patients with a longer progression-free survival (FDR-adjusted p=0.007, p=0.011, and p=0.013 respectively). Repeat element analysis showed an increase in long terminal repeats on-therapy in exceptional responders, suggesting induction of repeat element expression with epigenetic therapy. A higher expression of MAGE family tumor associated antigens (MAGEA10, MAGEB1, MAGEB2) was noted post-epigenetic therapy in exceptional responders. Conclusions: Genomic and transcriptomic analyses reveal the potential of epigenetic-priming to re-shape the tumor microenvironment and highlight patients that could benefit from combination epigenetic therapy with immunotherapy. Citation Format: Blair V. Landon, Kristen A. Marrone, Michael J. Topper, Akshaya Annapragada, Hua-Ling Tsai, Archana Balan, Noushin Niknafs, Christopher Cherry, James R. White, Gavin Pereira, Vilmos Adleff, Chen Hu, Joanne Riemer, Margaret Fitzpatrick, Patrick Forde, Christine L. Hann, Ronan J. Kelly, David S. Ettinger, Benjamin Levy, Jorge Nieva, James Herman, Victor E. Velculescu, Stephen Baylin, Julie Brahmer, Valsamo Anagnostou. Comprehensive genomic and transcriptomic analyses capture the effects of epigenetic therapy priming on immune checkpoint blockade response in non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6551.

- Tim Behrend, Nancy K. Florida, Javanese literature in Surakarta manuscripts; Volume 2; Manuscripts of the Mangkunagaran palace. Ithaca, New York: Cornell University Southeast Asia Program, 2000, 575 pp. - Harold Brookfield, Judith M. Heimann, The most offending soul alive; Tom Harrisson and his remarkable life. Honolulu: University of Hawai’i Press, 1998, 468 pp. - Harold Brookfield, Victor T. King, Rural development and social science research; Case studies from Borneo. Phillips, Maine: Borneo Research Council, 1999, xiii + 359 pp. [Borneo Research Council Proceedings Series 6.] - J.G. de Casparis, Roy E. Jordaan, The Sailendras in Central Javanese history; A survey of research from 1950 to 1999. Yogyakarta: Penerbitan Universitas Sanata Dharma, 1999, iv + 108 pp. - H.J.M. Claessen, Francoise Douaire-Marsaudon, Les premiers fruits; Parenté, identité sexuelle et pouvoirs en Polynésie occidentale (Tonga, Wallis et Futuna). 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During physical distancing, children do not meet their peers to play or talk together. Peer relationships have a crucial influence on all child development, especially for social skills or behaviour during early childhood. This study aims to determine changes in children's social behaviour during physical distancing during the Covid-19 pandemic. This research method is a descriptive quantitative study designed with the percentage value was used as a score for measuring the results of parental observations of children concerning the child's social behaviour instrument. Quota sampling (150 parents) was used to reach participants from various cities in Indonesia to see cultural differences. Data on children's social behaviour was obtained using the Preschool and Kindergarten Behaviour Scale (PKBS) tests. The data were then analysed using descriptive statistics. The results show that there are changes in children's social behaviour during physical distancing. Children who are less independent (58.9%) are the biggest decline in social behaviour reported by parents, while the one who changes the least is cleaning up the mess that has been made (38.7%). The implication of the results of this study is that parents should continue to pay attention to their children's social behaviour by providing opportunities for children to interact with peers in the house while still paying attention to health protocols. Keywords: Early Childhood, Social Behaviour, Physical Distancing References: Aksoy, P., & Baran, G. (2010). Review of studies aimed at bringing social skills for children in preschool period. Procedia - Social and Behavioural Sciences, 9, 663–669. https://doi.org/10.1016/j.sbspro.2010.12.214 Al-Tammemi, A. B. (2020). The Battle Against COVID-19 in Jordan: An Early Overview of the Jordanian Experience. Frontiers in Public Health, 8(May), 1–6. https://doi.org/10.3389/fpubh.2020.00188 Arkorful, V., & Abaidoo, N. (2015). 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The poetic, prose and memoir works of Ukrainian writer Stepan Budnyi are considered in the article. He has left a noticeable mark in the history of Ukrainian literature of the 1950s. The focus of the research includes the analysis of the song concept, used frequently by the author and designated as a genre (in his own works). Many poetic works of S. Budnyi, characterized by melodiousness, emotionally elevated mood, simplicity of expression, vivid imagery, and the presence of striking figurative details, have a musical orientation. The frequency of the poet’s use of the song lexeme is counted in the article, indicating the folk-song character of S. Budnyi’s entire poetic heritage. This is reflected particularly in the titles of poetic works, evoking musical associations simultaneously. The poet has preferred those poetic works containing musical terminology in his translations from various languages. It is revealed that S. Budnyi’s relatively small prose heritage also includes musical motifs. Similar to poetry, the song in the writer’s prose works holds a distinct place and is a leading motif throughout his entire creative output. The author’s position and understanding of the essence of beauty are traced through the expressions of the lyrical heroes in prose sketches about music, song and dance. The author’s appeals to song and music are also considered in the writer’s epistolary. Texts by S. Budnyi, set to music by various Ukrainian composers such as Yaroslav Vyshyvanyi, Oleh Herman, Bohdan Klymchuk, Bohdan and Ivan Kravchuk brothers, Faina Moldavska, Volodymyr Obukhivskyi, Mykhailo Obleshchuk, Andrii Plishka, and others, are distinguished. Attention is drawn to the linguistic features of the writer’s artistic works, emphasizing especially that the author’s neologisms, used frequently, imbue the texts with a peculiar musicality. In general, Stepan Budnyi’s poetry has an original sound, impressing with a variety of artistic means, especially the vivid metaphorical expressions.

Two new species of the hitherto monotypic family Intramolgidae are described, both are placed in the type genus Intramolgus Marchenkov & Boxshall, 1995. Intramolgus heardensis sp. nov. was found in association with Polyzoa opuntia Lesson, 1830, and the host of I. atlantis sp. nov. was Styela chaini Monniot C. & Monniot F., 1970. Eleven new species belonging to the family Lichomolgidae are reported. These include four new monotypic genera: Antarctomolgus gen. nov. accommodates A. molgulae gen. et sp. nov. from Molgula pedunculata (Herdman, 1881), Didemnomolgus gen. nov. accommodates D. crenulatus gen. et sp. nov. from Didemnum molle (Herdmann, 1886), Spheromolgus gen. nov. accommodates S. rarus gen. et sp. nov. from Diplosoma simile (Sluiter, 1909), and Alupa gen. nov. accommodates A. geminata gen. et sp. nov. from Leptoclinides madara Tokioka, 1953. The remaining new species are: Debruma deplanata sp. nov. from Ascidia ornata Monniot F. & Monniot C., 2001, Lichomolgidium bipartitum sp. nov. from Pyura stolonifera (Heller, 1878), Lichomolgus papuensis sp. nov. from Rhopalaea circula Monniot F. & Monniot C., 2001, L. brevicaudatus sp. nov. from an unidentified species of Polycarpa Heller, 1877, L. alatus sp. nov. from Synoicum castellatum Kott, 1992, L. lepidotus sp. nov. from Aplidium altarium (Sluiter, 1909), and Lobomolgus foveolatus sp. nov. from Didemnum molle (Herdmann, 1886). In addition, redescriptions are provided for Henicoxiphium redactum Illg & Humes, 1971, Lichomolgidium sardum Kossmann, 1877, Lichomolgus canui Sars, 1917, L. forficula Thorell, 1860, and Zygomolgus dentatus Kim I.H., 2006.

BackgroundDetection of structural lesions of the sacroiliac joint (SIJ) in patients with chronic low back pain is crucial for the diagnosis and classification of axial spondyloarthritis (axSpA). With MRI becoming a part of a routine diagnostic approach of axSpA, the question about the value of T1-weighted images (T1WI) evaluating structural lesions raised.ObjectivesTo construct and validate a radiomics model based on T1WI to assess SIJ structural lesions in patients with suspected axSpA.MethodsA total of 266 patients with clinical suspicion of axSpA between December 2016 and January 2022 were enrolled. Structural lesions were assessed by low-dose CT (ldCT) and MRI, respectively. Radiomics features, extracted from SIJ T1WI, were included to generate the radiomics model. Performance of the radiomics model was evaluated by the receiver operating characteristic curve. Point-biserial correlation analysis was used to interpret the associations between the radiomics features and structural lesions.ResultsStructural lesions were found in 122 of 187 patients (65.2%) in the training cohort and 52 of 79 patients (65.8%) in the validation cohort. Using ldCT as the gold standard, the area under the curves (AUCs) of the radiomics model and MRI experienced raters were 0.82 (95% CI: 0.76, 0.88) vs 0.73 (95% CI: 0.67, 0.79) in the training cohort, and 0.82 (95% CI: 0.72, 0.91) vs 0.74 (95% CI: 0.66, 0.83) in the validation cohort. The seven radiomics features included showed significant correlation with various structural lesions (Pall <0.05). Among them, Wavelet.LHL_firstorder_90Percentile showed the strongest association with fat lesion (r = 0.48,P<0.05).ConclusionThe radiomics analysis with T1WI could effectively detect SIJ structural lesions and each radiomics feature was correlated with different structural lesions significantly, which might inform radiomic-based applications for axSpA intelligent diagnosis.References[1]van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 1984;27(4):361-8.[2]Bakker PA, van den Berg R, Lenczner G, Thevenin F, Reijnierse M, Claudepierre P, et al. Can we use structural lesions seen on MRI of the sacroiliac joints reliably for the classification of patients according to the ASAS axial spondyloarthritis criteria? Data from the DESIR cohort. Ann Rheum Dis. 2017;76(2):392-8.[3]Poddubnyy D, Gaydukova I, Hermann KG, Song IH, Haibel H, Braun J, et al. Magnetic resonance imaging compared to conventional radiographs for detection of chronic structural changes in sacroiliac joints in axial spondyloarthritis. The Journal of rheumatology. 2013;40(9):1557-65.[4]Ye L, Liu Y, Xiao Q, Dong L, Wen C, Zhang Z, et al. MRI compared with low-dose CT scanning in the diagnosis of axial spondyloarthritis. Clin Rheumatol. 2020;39(4):1295-303.[5]Diekhoff T, Hermann KG, Greese J, Schwenke C, Poddubnyy D, Hamm B, et al. Comparison of MRI with radiography for detecting structural lesions of the sacroiliac joint using CT as standard of reference: results from the SIMACT study. Ann Rheum Dis. 2017;76(9):1502-8.Figure 1.The heatmap depicting the correlation between the included radiomic features and structural lesions. Intensities indicate high positive (red) and negative (blue) correlations.**: P<0.05; *: P<0.01.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

The pandemic of COVID-19 has afflicted every individual and has initiated a cascade of directly or indirectly involved events in precipitating mental health issues. The human species is a wanderer and hunter-gatherer by nature, and physical social distancing and nationwide lockdown have confined an individual to physical isolation. The present review article was conceived to address psychosocial and other issues and their aetiology related to the current pandemic of COVID-19. The elderly age group has most suffered the wrath of SARS-CoV-2, and social isolation as a preventive measure may further induce mental health issues. Animal model studies have demonstrated an inappropriate interacting endogenous neurotransmitter milieu of dopamine, serotonin, glutamate, and opioids, induced by social isolation that could probably lead to observable phenomena of deviant psychosocial behavior. Conflicting and manipulated information related to COVID-19 on social media has also been recognized as a global threat. Psychological stress during the current pandemic in frontline health care workers, migrant workers, children, and adolescents is also a serious concern. Mental health issues in the current situation could also be induced by being quarantined, uncertainty in business, jobs, economy, hampered academic activities, increased screen time on social media, and domestic violence incidences. The gravity of mental health issues associated with the pandemic of COVID-19 should be identified at the earliest. Mental health organization dedicated to current and future pandemics should be established along with Government policies addressing psychological issues to prevent and treat mental health issues need to be developed. References World Health Organization (WHO) Coronavirus Disease (COVID-19) Dashboard. 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Background:Depression is present in up to half of patients with Rheumatoid Arthritis (RA). The association between this mood disorder and disease activity scores, including DAS28, SDAI and CDAI, has previously been described by various authors.Objectives:The aim of our study was assessed the effect of depression on the components of different disease activity scores.Methods:We performed a cross-sectional study of consecutive adults with RA, according to ACR/EULAR 2010 criteria. Sociodemographic data, comorbidities and current treatment were recorded. Disease activity was evaluated using DAS28-ESR, DAS28-CRP, SDAI and CDAI. Depression was assessed using PHQ-9 questionnaire. The PHQ-9 values were categorized in 4 groups as follows: 5 to 9, 10 to 14, 15 to 19, 20 or greater, represents mild, moderate, moderate/severe, and severe depression, respectively. A cutoff value of 10 or greater was set to define major depression. Statistical analysis: Student´s T, ANOVA and Chi2 tests. Multiple logistic regression.Results:Two hundred fifty eight patients were included, with a median (m) disease duration of 9 years (IQR 3.6-16.7). The m PHQ-9 score was 6 (IQR 2-12.3) and the prevalence of major depression was 33.7%. Patients with major depression had more tender and swollen joint count (TJC and SJC) (mean 4.9±4.3 vs 2.3±3.7, p<0.0001 and 2.9±3.3 vs 1.7±3.4, p=0.009), more pain (VAS [cm] mean 5.6±2.7 vs 3.3±2.6, p<0.0001), higher patient and physician global assessment (PGA and PhGA) (VAS [cm] mean 5.4±2.9 vs 3.1±2.5, p<0.0001 and 4.4±2.7 vs 2.4±2.4, p<0.0001) and CRP (mean 1.7±3.3 vs 0.7±1.1 mg/dl, p=0.01). ESR values were higher in the group with major depression, but the difference did not reach significance. Disease activity was higher in the depression group by all scores: DAS28-ESR (mean 4.3±1.4 vs 3.3±1.3, p<0.0001), DAS28-CRP (mean 3.9±1.4 vs 2.8±1.7, p<0.0001), SDAI (mean 19.2±12.7 vs 10.3±10.1, p<0.0001) and CDAI (mean 17.6±10.9 vs 9.6±9.9, p<0.0001). While 41 (15.9%) patients had high disease activity according to DAS28-ESR, only 34 (13.2%) had SDAI>26.In the multivariate analysis, evaluating the association of major depression with the different components of DAS28-ESR, DAS28-CRP, SDAI and CDAI, we observed that the presence of this mood disorder remained significantly associated with higher PGA in all the scores. In addition, a significant association was seen with higher TJC in both DAS28 scores.Conclusion:Patients with major depression had higher disease activity. It´s presence has a significantly association with the subjective items of the disease activity scores, particularly PGA. CRP value was the only objective component associated with depression.Disclosure of Interests:Carolina Ayelen Isnardi Speakers bureau: Bristol Myers Squibb, Janssen, Grant/research support from: Pfizer, Emilce Edith Schneeberger Speakers bureau: Abbvie, Amgen, Bristol Myers Squibb, Janssen, Eli Lilly, Boehringer Ingelheim, Pfizer, Genzyme, Grant/research support from: Pfizer, Dafne Capelusnik Speakers bureau: Bristol Myers Squibb, Grant/research support from: Pfizer, Marcela Bazzarelli: None declared, Laura Barloco: None declared, Eliana Soledad Blanco: None declared, Alejandro Benitez Speakers bureau: Abbvie, Novartis, Amgen, Federico Benavidez: None declared, SANTIAGO SCARAFIA: None declared, María Alicia Lazaro Speakers bureau: Abbvie, Rodolfo Perez Alamino Speakers bureau: Pfizer, Abbvie, Amgen, Bristol-Myers-Squibb, Lilly, Janssen, Novartis, Federico Colombres: None declared, María Paula Kohan: None declared, Julia Sosa: None declared, Luciana Gonzalez Lucero: None declared, Ana Lucía Barbaglia: None declared, Hernan Maldonado Ficco Speakers bureau: Pfizer, Abbvie, Jansen, Novartis, Bago, Bristol, Eli Lilly., Consultant of: Pfizer, Abbvie, Novartis, Jansen, Bago, Eli Lilly., Gustavo Citera Speakers bureau: Abbvie, Bristol-Myers-Squibb, Lilly, Jansen, Gema, Pfizer, Roche, Grant/research support from: Pfizer

<p><strong>1. How can we maintain a sustainable private practice in the current political and economic climate?</strong></p><p>Eugene Allers</p><p><strong>2. SASOP Clinical guidelines, protocols and algorithms: Development of treatment guidelines for bipolar mood disorder and major depression</strong></p><p> Eugene Allers, Margaret Nair, Gerhard Grobler</p><p><strong>3. The revolving door phenomenon in psychiatry: Comparing low-frequency and high-frequency users of psychiatric inpatient services in a developing country</strong></p><p>U A Botha, P Oosthuien, L Koen, J A Joska, J Parker, N Horn</p><p><strong>4. Neurophysiology of emotion and senses - The interface between psyche and soma</strong></p><p>Eugene Allers</p><p><strong>5. Suicide prevention: From and beyond the psychiatrist's hands</strong></p><p>O Alonso Betanourt, M Morales Herrera</p><p><strong>6. Treatment of first-episod psychosis: Efficacy and toleabilty of a long-acting typical antipsychotic </strong></p><p>B Chiliza, R Schoeman, R Emsey, P Oosthuizen, L KOen, D Niehaus, S Hawkridge</p><p><strong>7. Treatment of attention deficit hyperactivity disorder in the young child</strong></p><p>Helen Clark</p><p><strong>8. Holistic/ Alternative treatment in psychiatry: The value of indigenous knowledge systems in cllaboration with moral, ethical and religious approaches in the military services</strong></p><p>J Dill</p><p><strong>9. Treating Schizophrenia: Have we got it wrong?</strong></p><p>Robin Emsley</p><p><strong>10.Terminal questions in the elderly</strong></p><p>Mike Ewart Smith</p><p><strong>11. Mental Health Policy development and implementation in Ghana, South Africa, Uganda and Zambia</strong></p><p>Alan J Flisher, Crick Lund, Michelle Frank, Arvin Bhana, Victor Doku, Natalie Drew, Fred N Kigozi, Martin Knapp, Mayeh Omar, Inge Petersen, Andrew Green andthe MHaPP Research Programme Consortium</p><p><strong>12. What indicators should be used to monitor progress in scaling uo services for people with mental disorders?</strong></p><p>Lancet Global Mental Health Group (Alan J Flisher, Dan Chisholm, Crick Lund, Vikram Patel, Shokhar Saxena, Graham Thornicroft, Mark Tomlinson)</p><p><strong>13. Does unipolar mania merit research in South Africa? A look at the literature</strong></p><p>Christoffel Grobler</p><p><strong>14. Revisiting the Cartesian duality of mind and body</strong></p><p>Oye Gureje</p><p><strong>15. Child and adolescent psychopharmacology: Current trends and complexities</strong></p><p>S M Hawkridge</p><p><strong>16. Integrating mental illness, suicide and religion</strong></p><p>Volker Hitzeroth</p><p><strong>17. Cost of acute inpatient mental health care in a 72-hour assessment uniy</strong></p><p>A B R Janse van Rensburg, W Jassat</p><p><strong>18. Management of Schizophrenia according to South African standard treatment guidelines</strong></p><p>A B R Janse van Rensburg</p><p><strong>19. Structural brain imaging in the clinical management of psychiatric illness</strong></p><p>F Y Jeenah</p><p><strong>20. ADHD: Change in symptoms from child to adulthood</strong></p><p>S A Jeeva, A Turgay</p><p><strong>21. HIV-Positive psychiatric patients in antiretrovirals</strong></p><p>G Jonsson, F Y Jeenah, M Y H Moosa</p><p><strong>22. A one year review of patients admitted to tertiary HIV/Neuropsychiatry beds in the Western Cape</strong></p><p>John Joska, Paul Carey, Ian Lewis, Paul Magni, Don Wilson, Dan J Stein</p><p><strong>23. Star'd - Critical review and treatment implications</strong></p><p>Andre Joubert</p><p><strong>24. Options for treatment-resistent depression: Lessons from Star'd; an interactive session</strong></p><p>Andre Joubert</p><p><strong>25. My brain made me do it: How Neuroscience may change the insanity defence</strong></p><p>Sean Kaliski</p><p><strong>26. Child andadolescent mental health services in four African countries</strong></p><p>Sharon Kleintjies, Alan Flisher, Victoruia Campbell-Hall, Arvin Bhana, Phillippa Bird, Victor Doku, Natalie, Drew, Michelle Funk, Andrew Green, Fred Kigozi, Crick Lund, Angela Ofori-Atta, Mayeh Omar, Inge Petersen, Mental Health and Poverty Research Programme Consortium</p><p><strong>27. Individualistic theories of risk behaviour</strong></p><p>Liezl Kramer, Volker Hitzeroth</p><p><strong>28. Development and implementation of mental health poliy and law in South Africa: What is the impact of stigma?</strong></p><p>Ritsuko Kakuma, Sharon Kleintjes, Crick Lund, Alan J Flisher, Paula Goering, MHaPP Research Programme Consortium</p><p><strong>29. Factors contributing to community reintegration of long-term mental health crae users of Weskoppies Hospital</strong></p><p>Carri Lewis, Christa Kruger</p><p><strong>30. Mental health and poverty: A systematic review of the research in low- and middle-income countries</strong></p><p>Crick Lund, Allison Breen, Allan J Flisher, Ritsuko Kakuma, Leslie Swartz, John Joska, Joanne Corrigall, Vikram Patel, MHaPP Research Programe Consortium</p><p><strong>31. The cost of scaling up mental health care in low- and middle-income countries</strong></p><p>Crick Lund, Dan Chishlom, Shekhar Saxena</p><p><strong>32. 'Tikking'Clock: The impact of a methamphetamine epidemic at a psychiatric hospital in the Western Cape</strong></p><p>P Milligan, J S Parker</p><p><strong>33. Durban youth healh-sk behaviour: Prevalence f Violence-related behaviour</strong></p><p>D L Mkize</p><p><strong>34. Profile of morality of patients amitted Weskoppies Psychiatric Hospital in Sout frican over a 5-Year period (2001-2005)</strong></p><p>N M Moola, N Khamker, J L Roos, P Rheeder</p><p><strong>35. One flew over Psychiatry nest</strong></p><p>Leverne Mountany</p><p><strong>36. The ethical relationship betwe psychiatrists and the pharmaceutical indutry</strong></p><p>Margaret G Nair</p><p><strong>37. Developing the frameor of a postgraduate da programme in mental health</strong></p><p>R J Nichol, B de Klerk, M M Nel, G van Zyl, J Hay</p><p><strong>38. An unfolding story: The experience with HIV-ve patients at a Psychiatric Hospital</strong></p><p>J S Parker, P Milligan</p><p><strong>39. Task shifting: A practical strategy for scalingup mental health care in developing countries</strong></p><p>Vikram Patel</p><p><strong>40. Ethics: Informed consent and competency in the elderly</strong></p><p>Willie Pienaar</p><p><strong>41. Confronting ommonmoral dilemmas. Celebrating uncertainty, while in search patient good</strong></p><p>Willie Pienaar</p><p><strong>42. Moral dilemmas in the treatment and repatriation of patients with psychtorders while visiting our country</strong></p><p>Duncan Ian Rodseth</p><p><strong>43. Geriatrics workshop (Psegal symposium): Medico-legal issuess in geriatric psyhiatry</strong></p><p>Felix Potocnik</p><p><strong>44. Brain stimulation techniques - update on recent research</strong></p><p>P J Pretorius</p><p><strong>45. Holistic/Alternative treatments in psychiatry</strong></p><p>T Rangaka, J Dill</p><p><strong>46. Cognitive behaviour therapy and other brief interventions for management of substances</strong></p><p>Solomon Rataemane</p><p><strong>47. A Transtheoretical view of change</strong></p><p>Nathan P Rogerson</p><p><strong>48. Profile of security breaches in longerm mental health care users at Weskoppies Hospital over a 6-month period</strong></p><p>Deleyn Rema, Lindiwe Mthethwa, Christa Kruger</p><p><strong>49. Management of psychogenic and chronic pain - A novel approach</strong></p><p>M S Salduker</p><p><strong>50. Childhood ADHD and bipolar mood disorders: Differences and similarities</strong></p><p>L Scribante</p><p><strong>51. The choice of antipsychotic in HIV-infected patients and psychopharmacocal responses to antipsychotic medication</strong></p><p>Dinesh Singh, Karl Goodkin</p><p><strong>52. Pearls in clinical neuroscience: A teaching column in CNS Spectrums</strong></p><p><strong></strong>Dan J Stein</p><p><strong>53. Urinary Cortisol secretion and traumatics in a cohort of SA Metro policemen A longitudinal study</strong></p><p>Ugash Subramaney</p><p><strong>54. Canabis use in Psychiatric inpatients</strong></p><p><strong></strong>M Talatala, G M Nair, D L Mkize</p><p><strong>55. Pathways to care and treatmt in first and multi-episodepsychosis: Findings fm a developing country</strong></p><p>H S Teh, P P Oosthuizen</p><p><strong>56. Mental disorders in HIV-infected indivat various HIV Treatment sites in South Africa</strong></p><p>Rita Thom</p><p><strong>57. Attendanc ile of long-term mental health care users at ocupational therapy group sessions at Weskoppies Hospital</strong></p><p>Ronel van der Westhuizen, Christa Kruger</p><p><strong>58. Epidemiological patterns of extra-medical drug use in South Africa: Results from the South African stress and health study</strong></p><p>Margaretha S van Heerden, Anna Grimsrud, David Williams, Dan Stein</p><p><strong>59. 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BackgroundAdministrative linked health data (ALHD) facilitates epidemiological research of Ankylosing Spondylitis (AS) but best practice requires dataset validation[1]. While ICD10-code M45 is used to identify AS populations internationally it is also used to code “Rheumatoid arthritis of the spine”[2]. Neither background AS nor Rheumatoid arthritis (RA) is captured in ICD coding, unless actively flaring whilst the patient is admitted.ObjectivesTo define the accuracy of ICD 10 Australian Modification (ICD10AM) code M45 in identifying AS patients in a tertiary hospital.MethodsRetrospective audit of patients with an electronic hospital discharge code M45 between 2000 and 2015. Patient records were manually reviewed to confirm presence of AS based on following criteria a) radiological evidence of Grade IV sacroiliitis or “bamboo spine” b) fulfilment of classification criteria (1984 Modified NY, 1991 AMOR, 2002 ESSG and 2009 ASAS criteria)[3]c) letter from treating rheumatologist confirming AS d) Biological DMARD (bDMARD) prescription for treating confirmed AS. Cases that were not able to meet AS criteria and had a likely alternative diagnosis documented by their treating team had this detail noted, but not assessed against formal criteria.All patients were then evaluated to for presence of an RA code ever during that patient’s lifetime. Codes used to define RA included by codes M08.0* M8.2*, M8.3*, M8.4*, M8.8*, M8.9*, M05.*, M06.* (ICD10) or 714 (ICD9).ResultsOf 155 cases reviewed, eighty-six (55.4%) met audit criteria for AS. Of the 69 cases not meeting audit criteria for AS, 35 (72%) had RA ICD codes applied during their lifetime and a further 15 had background RA recorded in their notes. Five cases met AS audit criteria and had RA code applied. Excluding patients ever tagged with an RA code reduced AS case finding by 6% and raised overall accuracy to 67.5%. If background RA is also excluded, accuracy is 78.9%.ConclusionOverall raw accuracy of the ICD10AM M45 code in identifying AS patients was low, with RA acting as a significant confounder. This bears significant implications for international ALHD research reliant on this code for case finding. Excluding those ever coded with RA significantly improved accuracy and is recommended for future research. Our data support the call for scrutiny of international variations of ICD taxonomy[4].References[1]Bernatsky S, Lix L, O’Donnell S, Lacaille D. Consensus statements for the use of administrative health data in rheumatic disease research and surveillance.Journal of rheumatology. 2013;40(1):66-73. doi:10.3899/jrheum.120835[2]ICD-10-CM Code for Ankylosing spondylitis M45. American Hospital Association. URL: Accessed 09/01/2023, 2023.https://www.aapc.com/codes/icd-10-codes/M45[3]Sieper, J., Rudwaleit, M., Baraliakos, X., Brandt, J., Braun, J., Burgos-Vargas, R., Dougados, M., Hermann, K. G., Landewé, R., Maksymowych, W., & van der Heijde, D. (2009). The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis.Annals of the rheumatic diseases,68 Suppl 2, ii1–ii44.https://doi.org/10.1136/ard.2008.104018[4]Jetté N, Quan H, Hemmelgarn B, Drosler S, Maass C, Moskal L, et al. The Development, Evolution, and Modifications of ICD-10: Challenges to the International Comparability of Morbidity Data. Medical Care. 2010;48(12):1105-10.Table 1.AS (%)TOTALS86 (55)Male56 (65)Female30 (35)Mean age at diagnosis (years)43Met clinical criteria37Met Radiological criteria31Specialist diagnosis with or without bDMARD prescription80Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Abstract The profound benefit of immune checkpoint blockade for cancer therapy is restricted to limited subsets of patients with specific cancers. Many factors contribute to primary and acquired resistance to immune checkpoint blockade, including local accumulation of immunosuppressive metabolites such as the nucleoside adenosine and downstream adenosine receptor signaling. Pharmacological inhibition of adenosine generation and signaling are active areas of clinical investigation. Here we report a novel mechanism whereby adenosine suppresses anti-cancer immune responses by intracellular accumulation. We show that human T cells readily take up adenosine via equilibrative nucleoside transporter 1 (ENT1), suppressing proliferation and effector function by inhibition of de novo pyrimidine nucleotide synthesis in T cells. ENT1 expression increases upon T cell activation, suggesting uptake of extracellular adenosine is a mechanism to limit T cell responses in high adenosine environments. Quantitative mass spectrometry imaging reveals adenosine concentrations in human tumors up to the range of 100 µM - levels significantly greater than previously demonstrated and consistent with suppression of T cell responses. Deletion of ENT1 leads to potent control of tumor growth in syngeneic mouse models including KPC, a poorly immunogenic model of pancreatic ductal adenocarcinoma, and is associated with increased CD8+ T cell frequency, proliferation and cytokine production within tumors. Furthermore, ENT1 expression was observed by flow cytometry on human tumor-infiltrating CD8+ T cells. We have discovered and characterized EOS301984, a potent ENT1 antagonist that is currently being evaluated in patients with advanced solid tumors. EOS301984 blocks intracellular adenosine transport and restores pyrimidine levels in T cells activated in the presence of adenosine, resulting in enhanced tumor cell killing by memory T cells and increased ex vivo expansion of functional human tumor-infiltrating lymphocytes in adenosine-rich environments. Finally, in a humanized mouse model of triple negative breast cancer resistant to anti-PD-1 blockade (MDA-MB-231), combination of EOS301984 with nivolumab synergistically led to control of tumor growth. Thus, ENT1 inhibition represents a novel approach to augment anti-cancer immune responses through restoring pyrimidine nucleotide synthesis in T cells suppressed by adenosine. Citation Format: Theodore J. Sanders, Christopher S. Nabel, Margreet Brouwer, Annelise L. Hermant, Lucas Chaible, Jean-Philippe Deglasse, Angelique Pabois, Wilfried Cathou, Aurore Smets, Michael Deligny, Joao Marchante, Quentin Dubray, Marie-Claire Lettelier, Chiara Martinoli, Reece Marillier, Olivier De Henau, Yvonne McGrath, Matthew G. Vander Heiden, Erica Houthuys. Inhibition of equilibrative nucleoside transporter 1 relieves intracellular adenosine-mediated immune suppression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 734.

Harvey S. Levin obtained his Bachelor’s degree from City College of New York, in New York city, Ph.D. in Clinical Psychology from the University of Iowa, in Iowa City, completed his internships in Clinical Neuropsychology and Pediatric Psychology at the University of Iowa Hospitals in Iowa City and Clinical Psychology, Psychiatry and Pediatrics at the Illinois Masonic Medical Center in Chicago, and his fellowship in Neuropsychology at University of Iowa Hospitals in Iowa City.Dr. Levin started his career in 1972 as Instructor with the Department of Psychology at the University of Iowa and transitioned to The University of Texas Medical Branch (UTMB) in Galveston, Texas, in 1974, where he began an internationally renowned career in clinical work, teaching, and, most of all, pioneering research on traumatic brain injury (TBI). He ultimately became the Chela and Jimmy Storm Distinguished Professor in Surgical Research, Division of Neurosurgery, Department of Surgery in 1987. After leaving Texas for two years to take a position with the University of Maryland Medical System and Shock Trauma Institute in Baltimore, he moved back to Houston Texas in 1995 and established the Cognitive Neuroscience Laboratory (CNL) within the Department of Physical Medicine & Rehabilitation at Baylor College of Medicine, which was supported by federal grants, including funding from the National Institutes of Health, Department of Defense, Department of Veterans Affairs, and Centers for Disease Control and Prevention, and numerous private foundations. The CNL integrated rehabilitation and neuroplasticity research with multimodality brain imaging, clinical and neuropsychological assessment, and fluid biomarkers. Dr. Levin was Professor with the Departments of Physical Medicine and Rehabilitation where he served as Director of Research (1995-2014), Pediatrics, and Neurosurgery at Baylor College of Medicine. He was also a Research Scientist and the Director of the Center of Excellence for Traumatic Brain Injury at the Michael E. DeBakey Veterans Affairs Medical Center (2008-2013), and Adjunct Professor with the Department of Psychology at Rice University in Houston, Texas.Dr. Levin’s research focused on investigating both acute and long-term outcomes of mild to severe TBI in civilian and military populations, including cognitive and behavioral sequelae in relation to neuropathology using advanced brain imaging modalities. He began prospective, longitudinal studies of adults and children who had sustained TBI associated with closed head trauma upon joining UTMB and developed, in collaboration with Drs O’Donnell and Grossman, the Galveston Orientation and Amnesia Test (GOAT). The GOAT was the first measure to assess post-traumatic amnesia and orientation following moderate to severe TBI, is still most widely used by the clinicians and researchers, and it has been translated to 16 languages. The original publication, “Levin HS, O’Donnell VM, Grossman RG. The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury. J Nerv Ment Dis. 1979 Nov;167(11):675-84. doi: 10.1097/00005053-197911000-00004. PMID: 501342”, has over 1200 citations. This work continued with participation in the NINDS Traumatic Coma Data Bank and the organization of outcome assessments for NINDS-funded clinical trials of hypothermia to treat severe TBI. To monitor the quality of outcome data across performing sites, Dr. Levin and colleagues developed a code for the reliability of data collected and implemented the role of an outcome monitor who evaluated adherence to protocol across sites. Following establishment of the CNL, he pursued investigation of TBI outcomes across the lifespan using multimodality brain imaging and biomarkers, errorless learning, translational studies in collaboration with neuroscientists using animal models, and clinical trials of methylphenidate, progesterone, CDP-choline. Dr. Levin spent over 30 years researching neurobehavioral outcomes of head injury in children, starting with a small pilot study funded by the Shriners Hospital in 1991 and continuing with several cycles of a multicenter R01 grant funded by the National Institute of Health. In later years, he used his expertise as a member of several large consortiums, including the Long-term Impact of Military-Relevant Brain Injury Consortium \ Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) funded by the VA and DoD and the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) funded by the NINDS.During his career, Dr. Levin authored and coauthored more than 400 articles in scientific journals and over 100 books, with one of them, “Levin, H. S., Benton, A. L., & Grossman, R. G. (1982). Neurobehavioral consequences of closed head injury. Oxford University Press, USA”, having over 1100 citation, as well as book chapters that advanced knowledge of TBI, epilepsy, neurodegenerative diseases, and other illnesses that affect brain functioning. He was also very active as a reviewer on federal grant panels and as an editor and reviewer for the Journal of Neurotrauma, Journal of Clinical and Experimental Neuropsychology, Archives of Physical Medicine & Rehabilitation, Neuropsychology, Journal of the International Neuropsychological Society, Lancet, JAMA, Pediatrics, and other top-cited journals. He served as president of the International Neuropsychological Society in 1989-1990. Dr. Levin was a recipient of numerous prestigious awards, including the Javits Neuroscience Investigator Award, the Jennett-Plum Award for Research on Traumatic Brain Injury, the Distinguished Career Award by the International Neuropsychological Society, the American Congress of Rehabilitation Gold Key Award, the Distinguished Lifetime Contribution to Neuropsychology Award from the National Academy of Neuropsychology, as well as awards from other head injury and psychological organizations, including the International Brain Injury Association, the National Head Injury Foundation, the North American Brain Injury Society, Texas Psychological Association, and the Defense and Veterans Brain Injury Center. In addition to his stellar scientific accomplishments, Dr. Levin trained, mentored, and provided supervision to interns, fellows, postdocs, residents, medical and psychology students. He was the Director of an NCMRR/NIH T32 Postdoctoral Research Program, and training supervisor in neuropsychology for Baylor College of Medicine and for the Memorial Hermann TIRR Neuropsychology Postdoctoral Fellowship Programs. A passionate educator, he taught classes at Baylor College of Medicine, the University of Houston, and the National and Kapodistrian University of Athens Medical School in Greece and served as an evaluator for the American Board of Clinical Neuropsychology/American Board of Professional Psychology. He was often invited as a lecturer at numerous scientific organizations.The main objective of this symposium is to provide an overview of the current state of research in TBI while highlighting Dr. Levin’s contributions to this field. The symposium will start with a brief overview of Dr. Levin’s career (Dr. Randall S. Scheibel), followed by presentations focused on the assessment of adult TBI, including posttraumatic amnesia (Dr. Felicia C. Goldstein), the current state of pediatric TBI (Dr. L. Ewing-Cobbs), and novel imaging in TBI (Dr. Erin D. Bigler). There will be a brief discussion session at the end lead by Dr. Elisabeth A. Wilde.

BackgroundPatients with psoriatic arthritis (PsA) have an increased risk of cardiovascular disease, possibly due to a chronic inflammatory state.ObjectivesThe main objective of this study was to investigate whether vascular inflammation, measured with 18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT), is elevated in PsA patients.MethodsWe included 75 PsA patients with active peripheral arthritis (≥2 tender and swollen joints) from an ongoing clinical trial (EudraCT 2017-003900-28), and a retrospective group of 40 controls with melanoma, without distant metastases and not receiving immunotherapy. Both PsA patients and controls were aged 18-75 years. The main outcome measure was aortic vascular inflammation, which was measured using target-to-background-ratios (TBR) on PET/CT. Clinical disease activity in PsA was assessed with joint counts, body surface area and the composite measure Disease Activity index for PsA. Laboratory assessments included the inflammatory parameters C-reactive protein and Erythrocyte Sedimentation Rate. Vascular inflammation was compared between PsA patients and controls in univariate analysis with an unpaired t-test with equal variances. A multiple linear regression analysis was performed to adjust for age, gender, body mass index and mean arterial pressure (MAP). Associations of clinical parameters of disease activity in PsA with vascular inflammation were assessed using Spearman’s correlation coefficient.ResultsVascular inflammation was increased in PsA patients in comparison with controls (mean TBR for entire aorta respectively 1.53±0.15 and 1.42±0.13; P<0.001; Figure 1). This association remained significant after adjusting for gender, age, body mass index and mean arterial pressure (P=0.002). In individuals with PsA, vascular inflammation was not associated with disease-related parameters. There were no significant differences between PsA patients and controls regarding age, mean arterial pressure (MAP) and history of CVD. PsA patients had a higher BMI in comparison with healthy controls (Table 1).ConclusionAortic vascular inflammation was increased in patients with active PsA compared with controls. This evidence suggests that inflammation in PsA is not limited to skin and joints, but also involves the cardiovascular system.Table 1.Patients’ characteristicsCharacteristicaPsA (N=75)Controls (N=40)p-valueAge, years, median (IQR)53 (46-59)52 (42-59)0.353bMale sex43 (57.3)23 (57.5)1.000cBody Mass Index, kg/m2, mean±SD28.4±4.925.9±4.00.008dMean Arterial Pressure, mean±SD102.8±11.698.5±13.90.090dCurrent smoking10 (13.3)NAHistory of cardiovascular disease:HypertensionHyperlipidemiaDiabetesMyocardial infarctionCerebrovascular event12 (16.0)1 (1.3)2 (2.7)2 (2.7)06 (15.0)2 (5.0)001 (2.5)1.000c0.277c0.542c0.542c0.348cPsA duration, months, median (IQR)10.0 (1.0-123)NACurrent csDMARD use37 (49.3)NATJC (of 68 joints), median (IQR)4.0 (6.5-10.0)NASJC (of 66 joints), median (IQR)3.0 (5.0-9.0)NALEI count (1-6), median (IQR)0 (0.0-1.0)NABSA, median (IQR)1.0 (1.0-3.0)NACRP, median (IQR)1.0 (4.0-10.3)NALDL-cholesterol, mean±SD3.0±0.9NAaValues are expressed as n (%) unless stated otherwise.bMann-Whitney testcFisher’s exact testdIndependent Samples t-testAbbreviations. CRP = C-reactive protein, BSA = body surface area, LEI = Leeds Enthesits Index, DMARD = Disease Modifying Anti-Rheumatic Drugs, LEI = Leeds Enthesitis Index, LDL = low-density lipoprotein, NA= not available, PsA = psoriatic arthritis, SD = standard deviation, SJC = swollen joint count, TJC = tender joint countFigure 1.Increased vascular inflammation in the entire aorta and all separate aortic segments, assessed with the TBR, in PsA (n=75) in comparison with controls (n=40).***= P ≤ 0.001, **= P ≤ 0.01. Abbreviations: PsA = psoriatic arthritis.AcknowledgementsThis work was supported by Pfizer (New York, New York, USA). The collaboration project is cofunded by the PPP Allowance made available by Health~Holland, Top Sector Life Sciences & Health, to stimulate public–private partnerships (grant number: LSHM17074).The TOFA-PREDICT Author Group:A. van Tubergen,K. Hermans,M.E. Hettema,M.R. Kok,R.J. Bisoendial,A.W.R. van Kuijk,J. Wiegel,T.L.T.A. Jansen,A.C. Comarniceanu,L. Geurts – van Bon,L.G. Schipper,S.T.A. van Bijnen,S. Wijngaarden,A. Herman.Disclosure of InterestsNienke J. Kleinrensink: None declared, Wouter Foppen Grant/research support from: WF has received research grants from NovoNordisk and Pfizer which were paid to the institution., Negina Seddiqi: None declared, Harald Vonkeman Grant/research support from: Prof. H. Vonkeman reports having received grants, consulting fees or honorarium from AbbVie, Boehringer Ingelheim, Novartis, Pfizer, UCB, Janssen and Galapagos; all outside the submitted work., Karijn Suijkerbuijk Consultant of: Bristol-Myers Squibb, Merck Sharp and Dome, Abbvie, Pierre Fabre, Novartis, Sairopa. All paid to institution and outside the submitted work, Grant/research support from: Novartis, Roche, Merck Sharp and Dome. All paid to institution and outside the submitted work., Mylène Jansen: None declared, Pim de Jong Consultant of: Vifor Pharma and Philips Healthcare, Marloes W. Heijstek: None declared, Julia Spierings: None declared.

ABSTRAK Bencana kebakaran memberikan dampak yang mempengaruhi kehidupan dan harta benda. Besarnya dampak semakin parah di tempat-tempat dengan tingkat kesiapsiagaan bencana kebakaran yang rendah. Kesiapsiagaan bencana salah satu elemen penting dalam pengurangan risiko bencana dan meliputi kesadaran masyarakat, kesiapan memberikan tanggapan yang tepat dan pemulihan yang cepat. Masyarakat memiliki peran dalam mengurangi resiko kebencanaan kebakaran. Komunitas dan masyarakat perlu memperkuat dan meningkatkan kemampuan dalam kesiapsiagaan bencana pada daerah dan tingkat komunitasnya. Tujuan penelitian ini untuk mengetahui kesiapsiagaan masyarakat di Kelurahan Pekauman Banjarmasin dalam menghadapi bencana kebakaran. Penelitian ini menggunakan rancangan deskriptif kuantitatif. Penggumpulan data menggunakan kuesioner. Sampel sebanyak 74 kepala keluarga di Kelurahan Pekauman RT.09 RW.01 yang diambil dengan total sampling. Analisa data menggunakan distribusi frekuensi. Dari hasil penelitian diperoleh kesiapsiagaan masyarakat dalam menghadapi kebakaran mayoritas berada dalam kategori sangat siap sebanyak 44 (59,5%), dan paling sedikit berada di kategori hamper siap sebanyak 7 (9,5%). Pemberdayaan masyarakat dapat mencegah terjadinya bencana dan meningkatkan kesiapsiagaan jika terjadi kebakaran. Kata kunci: kebakaran, kesiapsiagaan, komunitas. DAFTAR PUSTAKA Arismawati, M.D & Wijaya, O. (2019). Analisis Kesiapsiagaan Masyarakat dalam Menghadapi Bencana Kebakaran Pada Kawasan Pemukiman Padat Penduduk (Studi Kasus Kelurahan Prawirodirjan Yogyakarta). Artikel Kesehatan Masyarakat, Universitas Ahmad Dahlan. Badan Nasional Penanggulangan Bencana. (2019). Daftar Bencana Informasi Indonesia (Dibi). Jakarta:BNPB Baker, L. R., & Cormier, L. A. (2012). Disaster Preparedness and Families of Children with Special Needs: A Geographic Comparison. Journal of Community Health, 38(1), 106–112. Chan, E. Y. Y., Kim, J. H., Lin, C., Cheung, E. Y. L., & Lee, P. P. Y. (2012). Is Previous Disaster Experience a Good Predictor for Disaster Preparedness in Extreme Poverty Households in Remote Muslim Minority Based Community in China?. Journal of Immigrant and Minority Health, 16(3), 466–472. Dantzler, D. (2013). Basic household disaster preparedness decisionalInfluences among male federal employees in the national Capital region. Dissertation Doctor of Philosophy Capella University. ProQuest LLC. UMI Number:3559889. Farisa, F.C. (2018). BNPB: Selama 2018, Ada 1.999 Kejadian Bencana Kebakaran. Kompas.com. Retrieved 5 November 2020 at 13:20 WITA From Https://Nasional.Kompas.Com/Read/2018/10/25/22572321/Bnpb-Selama-2018ada-1999-Kejadian-Bencana Gowing, J. R., Walker, K. N., Elmer, S. L., & Cummings, E. A. (2017). Disaster Preparedness among Health Professionals and Support Staff: What is Effective? An Integrative Literature Review. Prehospital and Disaster Medicine, 32(03), 321–328. Haswar, Andi. M. (2021). Ada 45 Kasus Kebakaran dalam 5 Bulan di Banjarmasin, 2 Orang Meninggal Dunia. Retrieved from https://regional.kompas.com/read/2021/05/20/215702278/ada-45-kasus-kebakaran-dalam-5-bulan-di-banjarmasin-2-orang-meninggal-dunia. Hermon, Dedi. (2015). Geografi Bencana Alam. Jakarta Jaslow, D., Ufberg, J., Yoon, R., McQueen, C., Zecher, D., & Jakubowski, G. (2005). Fire Safety Knowledge and Practices Among Residents of an Assisted Living Facility. Prehospital and Disaster Medicine, 20(02), 134–138. Kuntoro, C. (2017). Implementasi Manajemen Risiko Kebakaran Berdasarkan (Is) ISO 31000 PT Apac. Inti Corpora. HIGEIA, 1(4), pp. 109-119 Martanto, C., Aji, A., & Parman, S. (2017). Kajian Kesiapsiagaan Masyarakat dalam menghadapi Bencana Kebakaran di Kelurahan Kembangsari Kecamatan Semarang Tengah. Edu Geography,2LIPI-UNESCO/ISDR. (2006). Kajian Kesiapsiagaan Masyarakat dalam mengantisipasi Bencana Gempa Bumi dan Tsunami. Nakao, R., Kawasaki, R., & Ohnishi, M. (2019). Disaster preparedness of hillside residential area in Nagasaki city, Japan: evaluations regarding experiences related to a fire. Journal of Rural Medicine, 14(1), 95–102. National Fire Protection Association (NFPA). (2018). Standar for Portable Fire Extinguisherts. USA Nugroho. (2015). Preparedness Assessment Tools For Indonesia. Jakarta: Humanitarian Forum Indonesia & MDM. Pahriannoor, Fauzan, A., & Hadi, Z. (2020). Relationship Of Knowlage And Nurse Attitude With Fire Prevention And Management Of Fire Ar RSUD Ulin Banjarmasin In 2020. Artikel Kesehatan Masyarakat. pdf Thomas, Tracy N., Griffith, Michelle Leander ., Harp, Victoria., Joan P. Cioffi. (2015). Influences of Preparedness Knowledge and Beliefs on Household Disaster Preparedness. 64(35); 965-971 Yulia, F. C. (2020). Kesiapsiagaan Masyarakat Dalam Menghadapi Bencana Kebakaran di Kampung Pelangi Kota Semarang Tahun 2020. Retrived 7 Mei 2021, from http://lib.unnes.ac.id/41191/1/3201416048.

Objetivo: Describir los conocimientos sobre transmisión, sintomatología, acciones de prevención y control frente a dengue en la región Piura, Perú. Material y métodos: Análisis secundario de la sección 700 (salud) de la Encuesta Nacional de Programas Estratégicos 2014, realizada por el Instituto Nacional de Estadística e Informática a 113 073 habitantes de ≥14 años a nivel nacional (5 131 en Piura). Se analizaron las preguntas 701 al 704 sobre conocimientos de dengue. Las respuestas fueron analizadas según características demográficas y provincia de residencia. Además, se comparó los resultados de toda la región frente al promedio nacional. Resultados: En Piura, el 78,4% refirió que la transmisión de dengue es por la picadura de un mosquito, (solo 54,5% a nivel nacional). Hubo diferencias entre zonas urbana (84%) y rural (58,2%), y entre provincias. Los síntomas más recordados fueron fiebre (79,7%), cefalea (56,4%), dolor de huesos/articulaciones (30,3%) y escalofríos (28,7%). 96,9% acudiría a un establecimiento de salud si presentara síntomas (97,8% a nivel nacional). Conocimiento sobre control de mosquito fue menor del 50% de medidas adecuadas. Conclusiones: El conocimiento sobre algunos aspectos del dengue es aún limitado en la región Piura, siendo ésta la más endémica a nivel nacional. Se debe enfatizar en educación sanitaria a nivel poblacional para frenar el avance alarmante de este problema. 1. Guzman MG, Harris E. Dengue. Lancet. 2015;385(9966):453-65.2. Rey JR, Philip Lounibos P. Ecología de Aedes aegypti y Aedes albopictus en América y transmisión enfermedades. Biomédica. 2015;35:177-85. 3. Bouyer J, Chandre F, Gilles J, Baldet T. Alternative vector control methods to manage the Zika virus outbreak: more haste, less speed. Lancet Glob Health. 2016;4(6):e364. 4. Hermann LL, Gupta SB, Manoff SB, Kalayanarooj S, Gibbons RV, Coller BA. Advances in the understanding, management, and prevention of dengue. J Clin Virol. 2015;64:153-9. 5. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature. 2013;496:504–507. 6. Quintero J, Brochero H, Manrique-Saide P, Barrera-Pérez M, Basso C, Romero S, Petzold M, et al. Ecological, biological and social dimensions of dengue vector breeding in five urban settings of Latin America: a multi-country study. BMC Infect Dis. 2014;21:14:38. 7. Kroeger A, Lenhart A, Ochoa M, Villegas E, Levy M, Alexander N, et al. Effective control of dengue vectors with curtains and water container covers treated with insecticide in Mexico and Venezuela: cluster randomised trials. BMJ. 2006;332:1247–1252. 8. Paz-Soldán VA, Morrison AC, Cordova Lopez JJ, Lenhart A, Scott TW, Elder JP, et al. Dengue Knowledge and Preventive Practices in Iquitos, Peru. Am J Trop Med Hyg. 2015;93(6):1330-7. 9. Cáceres-Manrique FM, Vesga-Gómez C, Perea-Florez X, Ruitort M, Talbot Y. Conocimientos, Actitudes y Prácticas sobre Dengue en Dos Barrios de Bucaramanga, Colombia. Rev. salud pública. 2009;11(1):27-38. 10. Santos SL, Parra-Henao G, Silva MB, Augusto LG. Dengue in Brazil and Colombia: a study of knowledge, attitudes, and practices. Rev Soc Bras Med Trop. 2014;47(6):783-7. 11. Egedus VL, Ortega JM, Obando AA. Knowledge, perceptions, and practices with respect to the prevention of dengue in a mid-Pacific coastal village of Costa Rica. Rev Biol Trop. 2014;62(3):859-67. 12. Wong LP, AbuBakar S. Health beliefs and practices related to dengue fever: a focus group study. PLoS Negl Trop Dis. 2013;7(7):e2310. 13. Van Benthem BH, Khantikul N, Panart K, Kessels PJ, Somboon P, Oskam L. Knowledge and use of prevention measures related to dengue in northern Thailand. Trop Med Int Health. 2002;7(11):993- 1000. 14. Sala de Situación de Salud – Semana Epidemiológica N° 11 2017 [Internet]. Lima: Centro Nacional de Epidemiología, Prevención y Control de Enfermedades - Ministerio de Salud; 2017 [citado el 10 de octubre de 2017]. Disponible en: http://www.dge.gob.pe/portal/docs/vigilancia/sala/2017/salaSE11.pdf. 15. Ferreira MC. Geographical distribution of the association between El Niño South Oscillation and dengue fever in the Americas: a continental analysis using geographical information system-based techniques. Geospat Health. 2014;9(1):141-51. 16. Encuesta Nacional de Programas Estratégicos 2011-2014 [Internet]. Lima: Instituto Nacional de estadística e Informática; 2015 [citado el 10 de octubre de 2016]. Disponible en: https://www.inei.gob. pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1291/libro.pdf 17. Palma-Pinedo H, Cabrera R, Yagui-Moscoso M. Factors behind people's reluctance towards dengue vector control actions in three districts in northern Peru. Rev Peru Med Exp Salud Publica. 2016;33(1):13-20. 18. OMS habla de una epidemia por dengue en región Piura [Internet]. Lima: CMP noticias; 2016 [citado el 10 de octubre de 2016]. Disponible en: https://cmp.org.pe/oms-habla-de-una-epidemiapor- dengue-en-la-region-piura/ 19. Gyawali N, Bradbury RS, Taylor-Robinson AW. Knowledge, attitude and recommendations for practice regarding dengue among the resident population of Queensland, Australia. Asian Pac J Trop Biomed. 2016;6(4):360–366. 20. Malhotra G, Yadav A, Dudeja P. Knowledge, awareness and practices regarding dengue among rural and slum communities in North Indian city, India. Int J Med Science and Public Health. 2014;3(3):295-299. 21. Hairi F, Ong CH, Suhaimi A, Tsung TW, Sundaraj C, Soe MM, et al. A knowledge, attitude and practices (KAP) study on dengue among selected rural communities in the Kuala Kangsar district. Asia Pac J Public Health. 2003;15(1):37-43. 22. Dhimal M, Aryal KK, Dhimal ML, Gautam I, Singh SP, Bhusal CL, et al. Knowledge, attitude and practice regarding dengue fever among the healthy population of highland and lowland communities in central Nepal. PLoS One. 2014;9(7):e102028.

Introducción: La enfermedad renal crónica asociada a la obesidad (ERC-AO) es una enfermedad con aumento en la prevalencia en las últimas décadas. Se caracteriza por un exceso de desequilibrios hormonales adipocíticos (adipoquinas), desregulación del sistema de equilibrio energético y desequilibrios en la homeostasis metabólica. Propósito de la revisión: El objetivo de la revisión es delinear el papel de los diferentes mecanismos fisiopatológicos para el desarrollo de enfermedad renal funcional o anatómica en pacientes con obesidad. Buscamos reportes actualizados en donde se incluye los resultados de mejor supervivencia para los pacientes con ERC-AO. Recientes hallazgos: Actualmente sabemos la ERC-AO tiene un comportamiento pro inflamatorio crónico. La obesidad y sobrepeso se asocian alteraciones hemodinámicas, estructurales e histopatológicas en el riñón, así como alteraciones metabólicas y bioquímicas que predisponen a la enfermedad renal, aun cuando la función renal y las pruebas convencionales sean normales. Conclusiones: Clasificamos a la ERC-AO en Tipo 1: Obesidad y alteraciones funcionales potencialmente reversibles. Tipo 2: Obesidad y alteraciones estructurales histopatológicas potencialmente no reversibles (Incluye la Glomerulopatía asociada a obesidad y glomeruloesclerosis focal y segmentaria). Tipo 3: Obesidad en relacionada con enfermedades crónicas (Diabetes, Hipertensión, Hipertensión pulmonar. Insuficiencia Cardíaca). Tipo 4: Obesidad en el paciente con terapia sustitutiva de la función renal. Recibido: Agosto 03, 2022 Aceptado: Septiembre 30, 2022 Publicado: Septiembre 30, 2022 Editor: Dr. Franklin Mora Bravo. Introducción La obesidad es una enfermedad en crecimiento con un aumento en su prevalencia en las últimas décadas, asociándose a un elevada carga asistencial y económica para los sistemas sanitaros derivado de su relación con enfermedades cardiovasculares, endocrinas, psicológicas, renales entre otras [1, 2]. El incremento en las tasas de obesidad en distintos grupos etarios, desde niños hasta adultos jóvenes conlleva a asumir que en el futuro veremos más enfermedad renal relacionada con la obesidad (ERC-AO) en la población general, con implicaciones relevantes para los sistemas de atención [3]. Por ello el conocimiento y comprensión de esta interacción podría tener implicaciones en la prevención y tratamiento de las enfermedades renales. Dentro de la población general la obesidad se asocia a incremento en el riesgo de diversas condiciones patológicas, como la hipertensión arterial crónica (HTA), enfermedad renal crónica (ERC), artrosis, infecciones, síndrome de apnea hipopnea obstructiva del sueño (SAHOS) y diabetes mellitus (DM) entre otras [3]. No obstante, en el escenario de la ERC, la obesidad juega un rol dual y paralelo en el desarrollo de la enfermedad, tradicionalmente se ha denominado “paradoja de la obesidad”, donde por un lado actúa como un factor de riesgo modificable para el desarrollo de la enfermedad renal crónica (ERC) y por otro se ha asocia de manera consistente con mejores resultados de supervivencia en pacientes con enfermedad renal terminal [1]. Por lo anterior, en las próximas páginas describimos aspectos fisiopatológicos que involucran la obesidad en el desarrollo de la ERC. Definición y epidemiología La obesidad es una condición que se caracteriza por la acumulación anormal o excesiva de tejido adiposo con consecuencias patológicas adversas e incremento del riesgo cardiovascular [4]. Utilizando para su definición y diagnostico un indicador simple como es la relación entre el peso y la talla denominado índice de masa corporal (IMC), se calcula dividiendo el peso de una persona en kilos por el cuadrado de su talla en metros (kg/m2). Un IMC entre 18.5 y 25 kg/m2 es considerado por la Organización Mundial de la Salud (OMS) como peso normal, un IMC entre 25 y 30 kg/m2 como sobrepeso y un IMC > 30 kg/m2, como obesidad [5-7]. Además, la obesidad puede ser clasificada en tres niveles de severidad: clase I (IMC 30.0 – 34.9), clase II (IMC 35.0 – 39.9) y clase III (IMC > 40) [8]. Durante las últimas tres décadas, la prevalencia de adultos con sobrepeso y obesidad (IMC ≥ 25 kg/m2) en todo el mundo ha aumentado sustancialmente, convirtiendo a la obesidad en una epidemia y se prevé que su prevalencia crezca un 40% en la próxima década [6]. Actualmente, el problema de obesidad se ha visto en mayor aumento debido al incremento en la afectación en niños, lo que ocasiona una mayor prevalencia de patologías a edad temprana. En 2016, según las estimaciones de la OMS unos 41 millones de niños menores de cinco años tenían sobrepeso o eran obesos [7]. Esto afectando a todos los países, independiente de su nivel de ingresos [7]. La prevalencia del sobrepeso y la obesidad en niños y adolescentes (de 5 a 19 años) ha aumentado de forma espectacular, del 4% en 1975 a más del 18% en 2016. Este aumento ha sido similar en ambos sexos: un 18% de niñas y un 19% de niños con sobrepeso en 2016. Mientras que en 1975 había menos de un 1% de niños y adolescentes de 5 a 19 años con obesidad, en 2016 eran 124 millones (un 6% de las niñas y un 8% de los niños) [7]. La creciente prevalencia de la obesidad tiene implicaciones para las enfermedades cardiovasculares (ECV) y también para la ERC. Un IMC alto es uno de los factores de riesgo más fuertes para la ERC de nueva aparición [6]. Epidemiología de la enfermedad renal crónica asociada a obesidad (ERC-AO) La enfermedad renal crónica (ERC) es una condición de interés en salud pública, asociada a una elevada morbilidad y mortalidad a nivel mundial. Las guías KDIGO (Kidney Disease: Improving Global Outcomes), definen la ERC como la presencia de alteraciones en la estructura o función renal durante al menos tres meses y con implicaciones para la salud [9, 10]. Los principales elementos clasificatorios para definir la presencia de ERC son la tasa de filtración glomerular (TFG) estimada (G1 a G5) utilizando como umbral definitorio una TFG 60 ml/min/1,73m2 y la tasa de excreción de albúmina en orina (A1 a A3) según el cociente albúmina/creatinina en una muestra aislada de orina sea < 30, 30-300 o > 300 mg/g, respectivamente [9, 10]. Si bien inicialmente existía cierta controversia sobre el uso de la TFG para el diagnóstico de la ERC en fases iniciales, trabajos recientes han puesto en evidencia que tanto una TFG< 60 ml/min/1.73 m2 como un cociente albúmina/creatinina (CAC) ≥ 1.1 mg/mmol (10 mg/g) son predictores independientes del riesgo de mortalidad e insuficiencia renal terminal (IRT) en población general [11, 12]. En consecuencia, debido a estas categorías podemos determinar el pronóstico de cada paciente. Los datos globales sugieren que la prevalencia de la ERC se encuentra entre el 10 y el 16 %, pero la información sobre la prevalencia de la población por categoría de TFG y ACR es escasa [13]. La ERC es una afección asociada a una elevada carga de morbilidad, mortalidad y enfermedad cardiovascular (ECV). A medida que disminuye la función renal, surgen trastornos metabólicos y hemodinámicos que aumentan las tasas de hospitalización, ECV y muerte [4]. El conjunto de factores de riesgo conocidos para la progresión de la ERC es relativamente pequeño, y las terapias y estrategias efectivas para retrasar la progresión de la ERC son limitadas [14]. Por lo cual resulta necesario conocer y entender los diferentes factores de riesgo y su impacto en el daño renal, en aras de lograr minimizar la progresión del mismo, sobre todo en aquellos en los cuales se puede realizar intervenciones activas, evaluables, controlables y con seguimiento continuo como es la obesidad. A la fecha existe suficiente evidencia para asociar la obesidad con el desarrollo y progresión de la enfermedad renal crónica. Los datos granulares sobre la prevalencia de la obesidad en personas con ERC son limitados pero consistentes en todo el espectro de la enfermedad renal. En la Encuesta Nacional de Examen de Salud y Nutrición de 2011–2014, el 44.1 % de los pacientes con ERC en los Estados Unidos también tenían obesidad (21.9 % con obesidad de clase 1 y 11.1 % con clase 2 y obesidad clase 3, habiéndose incrementado el porcentaje global un 5% en los últimos 12 años [15]. La glomeruloesclerosis focal y segmentaria (GEFS) es el tipo de glomerulonefritis que se asocia con mayor frecuencia a la obesidad [16]. La enfermedad glomerular habitualmente asociada a la obesidad se denomina glomerulopatía relacionada con la obesidad (GRO). Esta condición suele presentarse con síndrome nefrótico y pérdida progresiva de la función renal. Con la epidemia mundial de obesidad, se produjo un aumento progresivo de la GRO del 0.2% entre 1986 y 1990 al 2% entre 1996 y 2000, y se ha convertido en un tema emergente en el ámbito de la nefrología [15]. Etiología y patogénesis de la ERC-AO La obesidad se caracteriza por un exceso de desequilibrios hormonales adipocíticos (adipoquinas), desregulación del sistema de equilibrio energético y desequilibrios en la homeostasis metabólica [12]. Hay dos tipos de tejido adiposo presentes en los humanos: tejido adiposo blanco (WAT) y tejido adiposo marrón (BAT) [17-19]. El depósito de grasa ectópica primariamente ocurre en lugares donde no se almacena fisiológicamente, como el hígado, el páncreas, el corazón y el músculo esquelético; secundariamente hay un cambio en la distribución del tejido adiposo visceral con almacenamiento de tejido adiposo en los espacios intraperitoneal y retroperitoneal; luego se presenta la desregulación inflamatoria y de adipoquinas; y por último la resistencia a la insulina [20]. Tejido adiposo blanco (WAT) El tejido adiposo blanco (WAT) se caracteriza por ser un tejido blanco o amarillo con menor vascularización e inervación que el tejido marrón. Las células grasas tienen un tamaño que oscila entre 20 y 200 µm y contienen una única vacuola lipídica (uniloculares). En dicha vacuola se almacenan lípidos para su uso cuando hay demanda energética. De la totalidad de los lípidos que abarca la vacuola lipídica del adipocito blanco, del 90 al 99% son triacilgliceroles. El tejido adiposo blanco genera una gran cantidad de adipocinas y lipocinas. Las adipocinas son péptidos que actúan como hormonas o mensajeros que regulan el metabolismo. El tejido adiposo blanco se localiza en el tejido omental, mesentérico, retroperitoneal, perirrenal, gonadal y pericárdico [19]. Este tejido al igual que el tejido adiposo de otros sitios, está compuesto por una variedad de células que incluyen macrófagos, neutrófilos, células T CD4 y CD8, células B, neutrófilos, mastocitos, células T reguladoras y células T asesinas naturales (NK) [21, 22]. El tejido adiposo es responsable de la secreción de muchas moléculas de señalización, incluidas adipocinas, hormonas, citocinas y factores de crecimiento, como leptina, adiponectina, resistina, factor de necrosis tumoral-α (TNF-α), interleucina 6 (IL-6), monocito, proteína quimioatrayente-1 (MCP-1), factor de crecimiento transformante-β (TGF-β) y angiotensina II [23]. Tejido adiposo marrón o pardo (BAT) La coloración marrón del tejido adiposo se debe a que está más vascularizado y tiene un alto contenido de mitocondrias, las células grasas que componen el tejido adiposo pardo son multiloculares o tienen varias vacuolas lipídicas. Estas células tienen forma poligonal y miden de 15 a 50 µm. A diferencia del tejido adiposo blanco, el tejido marrón no tiene la función de almacenar energía, sino que la disipa a través de la termogénesis. Para lograr la regulación de la temperatura corporal, el tejido adiposo pardo se localiza en sitios superficiales y profundos [18]. Clasificación de la ERC-AO Se ha establecido que la obesidad es una enfermedad con un comportamiento pro inflamatorio crónico con múltiples comorbilidades asociadas [19]. El tejido adiposo como se describió previamente funciona como un órgano con actividad endocrina y esta infiltrado por diferentes poblaciones celulares que incluyen macrófagos y otras células con actividad inmune como linfocitos T, B y células dendríticas [19]. La mayor parte de la grasa corporal total, se considera como un sistema de órganos endocrinos, la perturbación de este tejido tiene como resultado una respuesta patológica al balance calórico positivo en individuos susceptibles que directa e indirectamente contribuye a la enfermedad cardiovascular y metabólica, se tiene conocimiento de tres principales mecanismos de disfunción del tejido adiposo “adiposopatía” [20]. Estos mecanismos incluyen alteraciones hemodinámicas, metabólicas e inflamatorias, lo que es la base de la clasificación de la ERC-AO propuesta en esta revisión (Tabla 1). ERC-AO tipo 1 La obesidad produce un daño renal de forma directa a través de alteraciones hemodinámicas, inflamatorias, y desregulación de factores de crecimiento y adipocitoquinas, además de aumento de leptina y disminución de adiponectina, aun cuando la función renal y las pruebas convencionales sean normales [16]. La obesidad desencadena una serie de eventos, que incluyen resistencia a la insulina, intolerancia a la glucosa, hiperlipidemia, aterosclerosis e hipertensión, todos los cuales están asociados con un mayor riesgo cardiovascular [4, 16] (Figura 1). La obesidad conduce a un incremento en la reabsorción tubular de sodio, alterando la natriuresis y provocando una expansión de volumen extracelular debido a la activación del sistema nervioso simpático (SNS) y el sistema renina-angiotensina-aldosterona (SRAA)(16). El aumento en la reabsorción tubular de sodio y la consiguiente expansión de volumen extracelular es un evento central en el desarrollo de HTA en la obesidad [4, 16]. Algunos estudios sugieren que se produce un aumento de la reabsorción de sodio en algunos segmentos además del túbulo proximal, posiblemente en el asa de Henle. Además, hay un aumento del flujo sanguíneo renal, la tasa de filtración glomerular (TFG) y la fracción de filtración [16]. La hiperfiltración glomerular, asociada con el aumento de la presión arterial y otras alteraciones metabólicas como la resistencia a la insulina y la DM, finalmente resultan en daño renal y disminución del filtrado glomerular [16]. Por otro lado, la activación del SNS también contribuye a la hipertensión relacionada con la obesidad [4]. Hay evidencia de que la denervación renal reduce la retención de sodio y la hipertensión en la obesidad, lo que sugiere que la activación del SNS inducida por la obesidad aumenta la presión arterial principalmente debido al estímulo de retención de sodio, más que a la vasoconstricción [16]. Los mecanismos que conducen a la activación del SNS en la obesidad aún no se conocen por completo, pero se han propuesto varios factores como desencadenantes de este estímulo, entre ellos la hiperinsulinemia, la hiperleptinemia, el aumento de los niveles de ácidos grasos, los niveles de angiotensina II y las alteraciones del reflejo barorreceptor. El aumento de los niveles de leptina está asociado a la activación del SNS y su efecto sobre el aumento de los niveles de presión arterial incluye también la inhibición de la síntesis de óxido nítrico (potente vasodilatador) [16, 24, 25].También se ha descrito un aumento de la producción de endotelina-1 en sujetos obesos, lo que contribuye aún más a la elevación de los niveles de presión arterial y, en consecuencia, a la disfunción renal. Estudios recientes han demostrado que la endotelina-1 está aumentada en pacientes con hipertensión intradiálisis, lo que sugiere que esta sustancia juega un papel clave en la génesis de la hipertensión en pacientes con ERC y posiblemente esté asociada con la hipertensión en pacientes obesos [16, 25]. Por lo anterior, las alteraciones hemodinámicas en los pacientes con obesidad conllevan a progresión de la ERC e incremento del riesgo cardiovascular derivado del desarrollo de enfermedades adicionales como la HTA, potencialmente estos cambios son reversibles con el control de la obesidad. ERC-AO Tipo 2 Mantener el estado de obesidad más allá de los efectos renales funcionales produce cambios estructurales irreversibles a nivel glomerular [25]. El estudio de pacientes con ERC y obesidad ha permitido identificar la presencia de enfermedad glomerular asociada a la obesidad, denominada glomerulopatía relacionada con la obesidad (GRO). En esta condición la hipertrofia glomerular parece ser la lesión inicial que estimula el borramiento de los podocitos y desencadena la respuesta inflamatoria local [25, 26]. Es relevante mencionar que las señales profibrogénicas inducen la formación de depósitos en la matriz extracelular de las nefronas, que conduce al engrosamiento de la membrana basal glomeruloesclerosis y fibrosis tubulointersticial [26]. Dentro del curso patogénico de la enfermedad la expansión de la superficie glomerular conduce a que los podocitos sean incapaces de cubrirla, esto lleva a disfunción y borramiento de los mismos, generando ruptura de la barrera de filtración glomerular con sobrecarga de las células restantes, lo que finalmente conduce a hiperfiltración y proteinuria [25, 26]. No obstante, no todos los pacientes con obesidad o IMC aumentado desarrollan ERC, lo cual sugiere que el incremento del IMC por sí solo no genera aumento en la incidencia o progresión de la ERC, ameritando alteraciones metabólicas adicionales. En los siguientes apartados se describen algunas de estas vías fisiopatológicas comunes a todos los tipos de ERC-AO. ERC-AO Tipo 3 La obesidad produce daño renal de forma secundaria ya que aumenta el riesgo de diabetes mellitus, hipertensión y daño cardiovascular, estas patologías causan enfermedad renal diabética (ERD), nefroangioesclerosis, y glomerulopatía asociada a hipertensión pulmonar e insuficiencia cardíaca. La mortalidad no solo se ve afectada por la presencia de la obesidad sino por la presencia de diabetes tipo 2, hipertensión arterial, hipertensión pulmonar e insuficiencia cardíaca. Los peores resultados en supervivencia lo padecen los pacientes con falla cardíaca, obesidad e insuficiencia renal. ERC-AO Tipo 4 En pacientes en hemodiálisis los niveles más elevados de adiponectina se asocian paradójicamente con tres veces más riesgo de muerte [24]. La obesidad se asocia a niveles muy bajos adiponectina por lo que la obesidad en el grupo poblacional que se realiza hemodiálisis es un fuerte factor protector con mejores resultados de supervivencia a 3 años comparados con pacientes con índice de masa corporal normal o baja. Mecanismos fisiopatológicos comunes en la ERC-AO Lipotoxicidad derivada del tejido adiposo En pacientes obesos el exceso de energía conduce a un microambiente sometido a estrés crónico, lo cual resulta en hipertrofia del tejido adiposo hasta que los adipocitos alcanzan su límite de crecimiento [25]. En ese momento, el exceso de especies toxicas lipídicas se acumula ectópicamente en diferentes órganos, induciendo un efecto nocivo conocido como lipotoxicidad; especialmente a nivel renal [27]. La lipotoxicidad se asocia a cambios estructurales y funcionales de las células mesangiales, podocitos y células tubulares proximales [28]. En los podocitos, esto interferiría con la vía de la insulina, crítica para la supervivencia y el mantenimiento de la estructura de los podocitos, lo que conduciría a la apoptosis de los podocitos e induciría una respuesta hipertrófica compensatoria en los podocitos restantes [25]. En el riñón, los depósitos de lípidos ectópicos contribuyen tanto a la inflamación local como al estrés oxidativo [27]. En modelos de ERD, la dislipidemia puede favorecer la acumulación de lípidos ectópicos e intermediarios lipídicos, no solo en el riñón sino también en tejidos extrarrenales como hígado, páncreas y corazón [27]. La acumulación de lípidos en el parénquima renal, genera daño en varias poblaciones celulares, incluídos podocitos, células epiteliales tubulares proximales y el tejido tubulointersticial a través de distintos mecanismos descritos en las siguientes apartados, pudiendo general compromiso a largo plazo de la función renal [27]. El tejido adiposo es una fuente importante de producción de diferentes factores proteicos activos, conocidos como adipocitocinas, las cuales participan en diferentes procesos metabólicos. Alteraciones en la secreción y señalización de moléculas derivadas del tejido adiposo durante la obesidad en gran medida puede mediar en la patogenia de los trastornos metabólicos [25]. A continuaciones se describe el rol de las adipocinas en la patogenia de la ERC y obesidad. Adiponectina La adiponectina es una proteína secretada principalmente por los adipocitos WAT, las principales funciones biológicas de la adiponectina incluyen una mayor biosíntesis de ácidos grasos y la inhibición de la gluconeogénesis hepática [17]. Es probablemente la adipocina secretada más abundantemente, forma alrededor del 0.05 % de las proteínas séricas y mide de 3 a 30 mg/ml en humanos, para su activación utiliza dos isoformas del receptor (AdipoR1 y AdipoR2) son receptores de siete transmembranas y tienen una homología del 66.7 % en su estructura [17]. Sin embargo, AdipoR1 y AdipoR2 son estructural y funcionalmente distintos de los receptores acoplados a proteína G porque su terminal N es intracelular, mientras que el terminal C es extracelular [29, 30]. La señalización de adiponectina se basa principalmente en interacciones de tipo receptor-ligando, en las que la adiponectina se une a sus receptores afines e inicia la activación de varias cascadas de señalización intracelular a través de las vías AMPK, mTOR, NF-κB, STAT3 y JNK [17]. La adiponectina inicia la activación de la señalización de AMPK mediada por la proteína adaptadora APPL1, que se une al dominio intracelular de AdipoR. Eso produce la activación de la biosíntesis de moléculas, otras proteínas reguladoras e importantes factores de transcripción. AMPK es un regulador que participa principalmente en la proliferación celular [17]. Hay dos tipos de macrófagos, M1 participan en la estimulación de los factores pro inflamatorios e induce la resistencia a la insulina y M2 bloquean una respuesta inflamatoria y promueve el metabolismo oxidativo; En los macrófagos, la adiponectina promueve la diferenciación celular de monocitos a macrófagos M2 y suprime su diferenciación a macrófagos M1, lo que muestra efectos pro inflamatorios y antiinflamatorios. Además, también activa los factores antiinflamatorios IL-10 pero reduce las citoquinas pro inflamatorias como IFN-γ, IL-6 y TNF-α en los macrófagos humanos [17]. Los pacientes con ERC muestran niveles elevados de proteína C reactiva (PCR), IL-6 y TNF-α y tienen una activación aberrante de receptor tipo toll (TLR)-4 [25]; en un estudio realizado en el año 2005 en 29 pacientes con ERC no diabéticos en etapa 5 y 14 controles sanos, se identificó que los pacientes con ERC tenían una expresión elevada del gen y la proteína TLR4, la estimulación de TLR-4 in vitro indujo la activación de TNF-α y NF-κB en células C2C12. Esto sugiere indirectamente que la activación de TLR-4 podría promover la inflamación muscular de los pacientes con ERC [31]. Los niveles de adiponectina se consideran predictivos de ERC, dado que estos se encuentran aumentados en pacientes con etapa pre diálisis [17, 29, 32]. Adicionalmente, en un estudio prospectivo realizado en el año 2008 en pacientes con ERC primaria no diabética identificó niveles elevados de adiponectina como un predictor novedoso de progresión de la ERC en hombres [33]. En estudios realizados en animales (ratones) muestran que la deficiencia de adiponectina se relaciona con varias alteraciones histológicas, incluida la fusión segmentaria procesos podocitarios, albuminuria y aumento del estrés oxidativo en los riñones [34]. Por otro lado, en pacientes obesos la producción de adiponectina se encuentra disminuida por lo que se cree que puede generar una función protectora sobre el riñón [29]. No obstante, paradójicamente, algunos estudios muestran que los pacientes con ERC y enfermedad renal crónica en diálisis (ERCT) tienen altos niveles de adipocinas, las explicaciones a esta situación son controversiales, se ha planteado podrían corresponder a un mecanismo compensatorio, otras consideraciones sugieren una disminución de la sensibilidad a la adiponectina o una reducción en el aclaramiento de la misma [35]. Leptina En pacientes con ERC independiente de la presencia de obesidad o no, se asocian a niveles elevados de leptina sérica. La leptina es una proteína de 167 aminoácidos, con una masa molecular de aproximadamente 16 kDa que está codificada por el gen LEP [23] secretada principalmente por los adipocitos, es una adipocina pleiotrópica. La leptina circulante llega a los órganos diana, donde se une a receptores específicos (conocidos como ObR, LR o LEPR), se conocen cinco isoformas del receptor de leptina en humanos (ObRa, ObRb, ObRc, ObRd y ObRe), de estas solo la isoforma ObRb (isoforma larga) se considera un receptor completamente activo, ya que es capaz de transducir completamente una señal de activación en la célula. Esta isoforma se encuentra altamente expresada en el sistema nervioso central (SNC), especialmente en el hipotálamo, donde participa en la regulación de la actividad secretora de este órgano. Los efectos de la leptina están mediados por cinco vías principales de señalización. Estas vías incluyen las vías de señalización JAK-STAT, PI3K, MAPK, AMPK y mTOR [23]. Por esta razón la principal función fisiológica de la leptina es transmitir información al hipotálamo sobre la cantidad de energía almacenada, como la masa de tejido adiposo, e influir en el gasto de energía al reducir el apetito. Regula el metabolismo energético, tiene efecto sobre la ingesta de alimentos, procesos de coagulación, angiogénesis, funciones relacionadas con la insulina y la remodelación vascular, además funciona como un pro inflamatorio molecular [36]. La leptina tiene efectos sobre el apetito y se ha demostrado que la hiperleptinemia contribuye a la hipertensión asociada a la obesidad por sobre activación del sistema nervioso simpático [37]. En cuanto al curso de la ERC, la leptina puede modular diferentes vías de señalización en el riñón, debido a que las células endoteliales glomerulares y mesangiales expresan abundantes receptores de leptina [25]. La leptina inducirá un incremento en la expresión de genes profibróticos, como TGF-β1 y citocinas pro inflamatorias [25]. El aumento en la expresión de TGF-β1, también contribuirá al desarrollarlo de la fibrosis renal, al unirse a receptores específicos a nivel renal, estimulara la expresión de factores profibróticos en un ciclo de retroalimentación positiva. Además, TGF-β1 es un potente iniciador de proliferación de células mesangiales renales [25]. Debido a su tamaño relativamente pequeño, la leptina atraviesa libremente el filtro glomerular de los riñones y luego se reabsorbe en la parte proximal de los túbulos contorneados [23]. Por lo que el estado elevado de leptina puede indicar una función renal deficiente [36]. Promueve la inflamación y trastorno de los lípidos, que contribuyen al riesgo de ERC [36]; se considera como “toxina urémica”, estando implicada tanto en la progresión de la enfermedad renal a través de efectos pro-hipertensivos y profibróticos, como en el desarrollo de complicaciones relacionadas con la ERC (inflamación crónica, pérdida de proteínas) [38]. Como se mencionó previamente, la leptina estimula la proliferación de células endoteliales glomerulares renales y aumenta la expresión de TGF-β1, un mediador clave de la hidrogénesis en estas células, el aumento de los niveles de leptina también contribuye al aumento de la expresión de colágeno tipo IV en el riñón, induce la proliferación de células mesangiales glomerulares mediante la activación de la vía PI3K, la hipertrofia de las células mesangiales aumenta la cantidad de proteína filtrada y albúmina que llega a las células del túbulo proximal y, como resultado, activa las vías inflamatorias y la fibrosis [23]. Puede presentarse un aumento en la síntesis del receptor TGFβ-1 secretado por las células endoteliales, este actúa de manera parácrina sobre el mesangio uniéndose a su receptor y activando la síntesis de proteínas de la matriz extracelular (ECM), incluyendo colágeno, fibronectina, tenazina y proteoglicanos; consiguientemente, un aumento en el nivel de TGFβ-1 conduce a la acumulación de MEC y, en consecuencia, a fibrosis glomerular y glomeruloesclerosis. En los podocitos, la leptina contribuye a la disminución de la expresión de las proteínas responsables de la filtración glomerular adecuada, incluidas la podocina, la nefrina, la podoplanina y la podocalixina. En las células del túbulo contorneado proximal (PTC), la leptina reduce la actividad metabólica de las células al activar la vía de señalización de mTOR [23]. Por otro lado, la leptina inhibe el apetito y aumenta el gasto de energía conduciendo a anorexia y desnutrición en pacientes con ERC, particularmente en casos de hemodiálisis de mantenimiento [36]. Por ende, una elevación de la leptina no solo nos indicaría daño renal, sino que además nos indica mayor progresión de complicaciones secundarias [39]. La obesidad aumenta la carga sobre los riñones y es un factor de riesgo de lesión renal, además de contribuir en los trastornos metabólicos asociados. Por lo que, teniendo en cuenta los efectos inhibitorios de la leptina sobre la obesidad, se puede considerar que puede proteger contra la lesión renal [39, 40]. Un estudio experimental publicado en el año 2017 demostró que la leptina disminuyó la ingesta calórica y los niveles de glucosa en ratas diabéticas [41], ese mismo año se publicó un estudio retrospectivo donde demostraron que la metreleptina, una metionil leptina humana recombinante, reduce el peso corporal y la dosis diaria de insulina en la diabetes mellitus tipo 1 [42]. La metreleptina ejerce efectos terapéuticos en la lipodistrofia [43], lo que indica que es probable que la leptina se aplique en los trastornos metabólicos [36]. Otras adipocinas Las principales adipocinas corresponden a la adiponectina y leptina como se ha descrito previamente. Además de estas, se distinguen la actividad de la visfatina y resistina, las cuales muestran propiedades pro-inflamatorias y efectos aterogénicos [25]. La visfatina estimula la expresión de TGF-β1, inhibidor del activador del plasminógeno-1 (PAI-1) y colágeno tipo I, los cuales han demostrado un rol importante como agentes profibróticos. Por otro lado, la resistina estimula la producción de las moléculas de adhesión como la molécula de adhesión intracelular 1 (ICAM-1) y la proteína de adhesión celular vascular 1 (VCAM-1) y promueve la activación del sistema renal simpático. Los niveles de estas adipocinas están marcadamente elevados en la obesidad y ERC correlacionándose con parámetros proinflamatorios y disminución de la tasa de filtración glomerular (TFG) [25, 37]. Durante el curso de la obesidad se presenta una sobre activación del SRAA, el tejido adiposo también estaría involucrado en la producción o estimulación de algunos de los componentes del RAS. Por ello la sobre estimulación del SRAA en obesos, asociado a la glomerulomegalia y desregulación de la reabsorción de sodio/glucosa, generalmente conlleva a hipertensión glomerular e hiperfiltración [25]. Otra adipocina a considerar, es la actividad de la adipocina proinflamatoria lipocalina 2 (LCN2), también denominada lipocalina asociada con la gelatinasa de neutrófilo (NGAL), estudiada como biomarcador funcional tanto para la enfermedad renal aguda como ERC(25). LCN2 es conocido por su papel en la respuesta inmune innata a través de su unión a sideróforos derivados de una infección bacteriana. Sin embargo, LCN2 no es secretada únicamente por neutrófilos sino también por otros tejidos como hígado, pulmones y de interés para este artículo, a nivel renal [25]. Se han informado niveles elevados de LCN2 en suero y orina en la lesión renal, debido a una expresión aumentada de LCN2 en el túbulo distal renal y una reabsorción alterada en el túbulo proximal [44]. El tejido adiposo, también puede producir factores angiogénicos como el factor de crecimiento del endotelio vascular (VEGF). Este elemento podría inducir la formación de novo de capilares glomerulares en gran parte defectuosos dentro del riñón, lo que contribuye a la hipertrofia glomerular característica de GRO [25] (Figura 2). Conclusiones La obesidad y el sobrepeso se asocian a alteraciones hemodinámicas, estructurales e histopatológicas en el riñón, así como alteraciones metabólicas y bioquímicas que predisponen a la enfermedad renal, aun cuando la función renal y las pruebas convencionales sean normales. Por lo tanto, los efectos renales de la obesidad son estructurales y funcionales. Hay varios mecanismos actualmente descritos que involucran a la obesidad como generador de alteraciones renales. Teniendo en cuenta las bases fisiopatológicas, proponemos una clasificación de la ERC-AO basadas en 4 tipos. Abreviaturas ERC: enfermedad renal crónica. ERC-AO: enfermedad renal crónica-asociada a enfermedad. VEGF: factor de crecimiento del endotelio vascular. OR: Odds ratio. Información suplementaria Materiales suplementarios no han sido declarados. Agradecimientos No aplica. Contribuciones de los autores Jorge Rico-Fontalvo: Conceptualización, Curación de datos, Análisis formal, Adquisición de fondos, Investigación, Metodología, Administración de proyecto, Recursos, Software, Escritura – borrador original. Rodrigo Daza-Arnedo: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Tomás Rodríguez-Yanez: Metodología, validación, supervisión, redacción: Revisión y edición. Washington Osorio: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Beatriz Suarez-Romero: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Oscar Soto: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Juan Montejo-Hernandez: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. María Cardona-Blanco: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Juan Camilo Gutiérrez: Conceptualización, Supervisión, Validación, Visualización, Redacción: revisión y edición. Todos los autores leyeron y aprobaron la versión final del manuscrito. Financiamiento Los autores proveyeron los gastos de la investigación. Disponibilidad de datos o materiales Los conjuntos de datos generados y analizados durante el estudio actual no están disponibles públicamente debido a la confidencialidad de los participantes, pero están disponibles a través del autor correspondiente a pedido académico razonable. Declaraciones Aprobación del comité de ética y consentimiento para participar No aplica para revisiones narrativas. Consentimiento para publicación No aplica cuando no se publican imágenes o fotografías del examen físico o radiografías/tomografías/resonancias de pacientes. Conflictos de interés Los autores reportan no tener conflictos de interés. 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Herman Melville’s Moby-Dick, a whaling story at the surface, wrenches out from its confines the deep-seated dilemma in human–nature relationship. Like all the other characters, Starbuck, the ship’s first mate, has a loosely bound but matter–of–fact association to Moby Dick, the white whale. His attitude towards Moby Dick is one of what he holds as a general outlook towards a whale. Unlike Captain Ahab, he is not obsessed with that particular animal. He commoditizes it, and thereby takes an anthropocentric stance as he sets himself on a mission to hunt down the great beast. The questions, however, remain whether his approach towards the whale(s) is justifiable and whether the counterstrike that he, together with his shipmates, faces in the end of the novel has any connection to such an approach or not. This paper intends to address such issues from the perspective of animal studies.

Few studies have examined the cost-effectiveness of the National Diabetes Prevention Program (NDPP) in real-world settings. We evaluated the real-world cost-effectiveness of the NDPP in people with prediabetes in a large workforce with employer-sponsored health insurance. We performed individual-level, empirical data analyses using surveys and health insurance claims for 6,179 adult employees, dependents, and retirees with prediabetes who enrolled (n=592) or did not enroll (n=5,587) in the NDPP. We assessed direct medical costs the year before NDPP enrollment/index date (baseline) through 2 years afterward, EQ-5D-5L utility scores at baseline and 2 years afterward, and quality-adjusted life-years (QALYs) over 2 years for NDPP enrollees and non-enrollees. We applied propensity score weighting to adjust for bias due to self-selection for enrollment, multiple imputations to handle missing data, and bootstrap method to produce confidence intervals (CIs). We adopted a health system perspective and discounted costs and QALYs at 3% annually. Costs were expressed in 2020 U.S. dollars. Compared to non-enrollees, the average reduction in direct medical costs per enrollee was $3,979 (95% CI: -$11,962 to $2,019) over 2 years. The cost savings were primarily related to fewer hospitalizations (-$3,016), outpatient visits (-$639), and emergency room visits (-$272) among enrollees. Each enrollee accrued 1.726 QALYs and each non-enrollee accrued 1.702 QALYs over 2 years, representing a gain of 0.024 (95% CI: -0.007 to 0.052) QALY per enrollee. The uncertainty analyses showed a high probability (75%) of cost savings, and an 89% probability of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY gained, for NDPP enrollees versus non-enrollees. In this real-world population with prediabetes, enrollment in the NDPP was likely to provide cost savings and improve quality-adjusted life-expectancy. Further research is warranted to confirm these findings. Disclosure S. Kuo: None. W. Ye: None. D. Wang: None. L.N. McEwen: None. C. Villatoro Santos: None. W.H. Herman: Consultant; Merck Sharp & Dohme Corp. Advisory Panel; American Diabetes Association. Other Relationship; National Institutes of Health. Advisory Panel; National Committee for Quality Assurance. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK109995 and P30DK092926), and Centers for Disease Control and Prevention (U18DP006712)

Dissolved oxygen (DO), total biomass and oxygen demand of nematode communities in the organic shrimp farms located in Tam Giang commune, Nam Can District, Ca Mau province were investigated in three seasons (March-dry, July-transfer and November-wet season) of 2015. The results showed that most of DO values were within permissible limits. However, the frequency distributions of DO values are very compressed at the lower limit of their scale. Total dry biomass varied from 24.77 to 937.04 µgC/10cm2 while oxygen demand ranged from 3467.39 to 64288.50 nlO2/day/10cm2. These values were slightly high when compared to other studies in the world. The following results recorded that the negatively correlation between DO and oxygen demand of nematode communities in the organic shrimp farms. This may well suggest that respiration and metabolic of nematode communities was high and their impact on oxygen dissolved in surface water. 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Introduction: The prevalence of dental anxiety appears to be relatively consistent throughout the world, but some studies reports higher levels than others. This may be related to different instruments used. Objective: to identify and describe the main instruments used in the assessment of dental anxiety in adolescents. Material and Methods: Literature review. Original studies involving adolescents, in which the methodology comprised the application of some instrument to identify and / or quantify the phenomenon, were included. The search was limited to English, Portuguese and Spanish publications in the period between 2012 and 2016. Reviews, Meta-analyzes and case reports were excluded. The selected databases were MEDLINE (via PubMed) and LILACS (via BVS); and the search was developed with the following descriptors: 'dental anxiety', 'adolescents', 'Surveys and Questionnaires' (MeSH), combined by the Boolean operator AND. Results: Ten psychometric instruments are available to assess dental anxiety. The most frequently used instrument is the Dental Anxiety Scale (DAS), presented in nine studies. Less frequently used is the Facial Image Scale (FIS), presented in only one investigation. Most of the instruments affords translations into other languages, including Portuguese. Conclusion: The most used instrument is the DAS, followed by its modified version, the MDAS. Usually, more than one instrument has been used to correlate the findings and to provide the measured construct a greater consistency.Descriptors: Dental Anxiety; Adolescent; Surveys and Questionnaires.ReferencesStenebrand A, Wide Boman U, Hakeberg M. Dental anxiety and symptoms of general anxiety and depression in 15‐year‐olds. Int J Dent Hyg. 2013; 11(2):99-104.American Psychiatric Association. DSM-5: Manual diagnóstico e estatístico de transtornos mentais. São Paulo:Artmed; 2014.Folayan MO, Idehen EE, Ojo OO. 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Abstract In health and social sciences, research questions often involve systematic assessment of the modification of treatment causal effect by patient characteristics. In longitudinal settings, time-varying or post-intervention effect modifiers are also of interest. In this work, we investigate the robust and efficient estimation of the Counterfactual-History-Adjusted Marginal Structural Model (van der Laan MJ, Petersen M. Statistical learning of origin-specific statically optimal individualized treatment rules. Int J Biostat. 2007;3), which models the conditional intervention-specific mean outcome given a counterfactual modifier history in an ideal experiment. We establish the semiparametric efficiency theory for these models, and present a substitution-based, semiparametric efficient and doubly robust estimator using the targeted maximum likelihood estimation methodology (TMLE, e.g. van der Laan MJ, Rubin DB. Targeted maximum likelihood learning. Int J Biostat. 2006;2, van der Laan MJ, Rose S. Targeted learning: causal inference for observational and experimental data, 1st ed. Springer Series in Statistics. Springer, 2011). To facilitate implementation in applications where the effect modifier is high dimensional, our third contribution is a projected influence function (and the corresponding projected TMLE estimator), which retains most of the robustness of its efficient peer and can be easily implemented in applications where the use of the efficient influence function becomes taxing. We compare the projected TMLE estimator with an Inverse Probability of Treatment Weighted estimator (e.g. Robins JM. Marginal structural models. In: Proceedings of the American Statistical Association. Section on Bayesian Statistical Science, 1-10. 1997a, Hernan MA, Brumback B, Robins JM. Marginal structural models to estimate the causal effect of zidovudine on the survival of HIV-positive men. Epidemiology. 2000;11:561–570), and a non-targeted G-computation estimator (Robins JM. A new approach to causal inference in mortality studies with sustained exposure periods - application to control of the healthy worker survivor effect. Math Modell. 1986;7:1393–1512.). The comparative performance of these estimators is assessed in a simulation study. The use of the projected TMLE estimator is illustrated in a secondary data analysis for the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial where effect modifiers are subject to missing at random.

Today, the incidence of type 2 diabetes mellitus is increasing rapidly on global. This disease is shown with many complications that significantly affect public health. One of them is kidney complications, which have a high incidence among diabetic patients in Vietnam (25.6-33.1%). Age, history of hypertension, and dyslipidemia are considered to be the main risk factors for diabetic nephropathy. Thus, early detection of these factors for kidney damage is significant for diagnosing, monitoring, treatment, and prognosis of diabetic patients. Our descriptive, cross-sectional study conducting on 120 diabetic patients at E Hospital has observed that blood cholesterol levels, HbA1c levels were independently related to eGFR decline below 60 mL/min/1.73m2. From those data, an equation to predict the risk of diabetic kidney disease was estimated as p = with k = Keyword: Type 2 diabetes, Diabetic nephropathy, Risk factor Today, the incidence of type 2 diabetes mellitus is increasing rapidly on global. This disease is shown with many complications that significantly affect public health. One of them is kidney complications, which have a high incidence among diabetic patients in Vietnam (25.6-33.1%). Age, history of hypertension, and dyslipidemia are considered to be the main risk factors for diabetic nephropathy. Thus, early detection of these factors for kidney damage is significant for diagnosing, monitoring, treatment, and prognosis of diabetic patients. Our descriptive, cross-sectional study conducting on 120 diabetic patients at E Hospital has observed that blood cholesterol levels, HbA1c levels were independently related to eGFR decline below 60 mL/min/1.73m2. From those data, an equation to predict the risk of diabetic kidney disease was estimated as p = with k = Keyword Type 2 diabetes, Diabetic nephropathy, Risk factor. References [1] N. H. Cho, J. Kirigia, J. C. Mnanya, K. Ogurstova, L. Guraiguata, W. Rathmann, G. Roglic, N. Forouhi, R. Dajani, A. Esteghmati, E. Boyko, L. Hambleton, O. L. M. Neto, P. A. Montoya, S. Joshi, J. Chan, J. Shaw, T.A. Samuels, M. Pavkov, A. Reja, IDF Diabetes Atlas Eight Edition, International Diabete Federation, England, 2017.[2] N. T. Khue, Diabetes – General Endocrinology, Ho Chi Minh Publisher, Ho Chi Minh city, 2003 (in Vietnamese). [3] H. H. Kiem, Clinical Nephrology, Medical Publishing House, Hanoi, 2010 (in Vietnamese). [4] T. H. Quang, Practice Diabetes - Endocrine Disease, Medical Publishing House Hanoi, Hanoi, 2010 (in Vietnamese). [5] D. T. M. Hao, T. T. A. 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A common ground between mental health and judicial-legal domains concerns concepts like “care”, “control” and “possibility to foresee” human behaviour, with particular reference to the “social dangerousness”. The connections between these sense-making practices can be traced by discursive modulation of “certainty/uncertainty”. This study aimed to highlight the discursive peculiarities of a specific socio-cultural context and genre, namely scientific papers. The corpus of data consisted in a selection of 30 papers published by the BJP (from 1975 to 2015), on subjects concerning forensic psychiatry, subjected to Content Analysis and Critical Discourse Analysis. Results showed that the papers adopted two main socio-epistemic rhetorics. On one side, the enunciators proceeded in an “assertive” and rigorous manner through a social-epistemic rhetoric of “reassurance”; on the other side, they gave voice to rhetoric of the “limit”, lacking any cognitive “closure”. References Bakhtin, M.M. 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I was born illegitimate. Born on an existential precipice. My unwed mother was 36 years old when she relinquished me. I was the fourth baby she was required to give away. After I emerged blood stained and blue tinged – abject, liminal – not only did the nurses refuse me my mother’s touch, I also lost the sound of her voice. Her smell. Her heart beat. Her taste. Her gaze. The silence was multi-sensory. When they told her I was dead, I also lost, within her memory and imagination, my life. I was adopted soon after but not told for over four decades. It was too shameful for even me to know. Imprinted at birth with a psychological ‘death’, I fell, as a Late Discovery Adoptee (LDA), into a socio-cultural and psychological abyss, frozen at birth at the bottom of a parturitive void from where, invisible within family, society, and self I was unable to form an undamaged sense of being.Throughout the 20th century (and for centuries before) this kind of ‘social abortion’ was the dominant script. An adoptee was regarded as a bastard, born of sin, the mother blamed, the father exonerated, and silence demanded (Lynch 28-74). My adoptive mother also sinned. She was infertile. But, in taking me on, she assumed the role of a womb worthy woman, good wife, and, in her case, reluctant mother (she secretly didn’t want children and was privately overwhelmed by the task). In this way, my mother, my adoptive mother, and myself are all the daughters of bereavement, all of us sacrificed on the altar of prejudice and fear that infertility, sex outside of marriage, and illegitimacy were unspeakable crimes for which a price must be paid and against which redemptive protection must be arranged. If, as Thomas Keneally (5) writes, “original sin is the mother fluid of history” then perhaps all three of us all lie in its abject waters. Grotevant, Dunbar, Kohler and Lash Esau (379) point out that adoption was used to ‘shield’ children from their illegitimacy, women from their ‘sexual indiscretions’, and adoptive parents from their infertility in the belief that “severing ties with birth family members would promote attachment between adopted children and parents”. For the adoptee in the closed record system, the socio/political/economic vortex that orchestrated their illegitimacy is born out of a deeply, self incriminating primal fear that reaches right back into the recesses of survival – the act of procreation is infested with easily transgressed life and death taboos within the ‘troop’ that require silence and the burial of many bodies (see Amanda Gardiner’s “Sex, Death and Desperation: Infanticide, Neonaticide, and Concealment of Birth in Colonial Western Australia” for a palpable, moving, and comprehensive exposition on the links between 'illegitimacy', the unmarried mother and child murder). As Nancy Verrier (24) states in Coming Home to Self, “what has to be understood is that separation trauma is an insidious experience, because, as a society, we fail to see this experience as a trauma”. Indeed, relinquishment/adoption for the baby and subsequent adult can be acutely and chronically painful. While I was never told the truth of my origins, of course, my body knew. It had been there. Sentient, aware, sane, sensually, organically articulate, it messaged me (and anyone who may have been interested) over the decades via the language of trauma, its lexicon and grammar cellular, hormonal, muscular (Howard & Crandall, 1-17; Pert, 72), the truth of my birth, of who I was an “unthought known” (Bollas 4). I have lived out my secret fatality in a miasmic nebula of what I know now to be the sequelae of adoption psychopathology: nausea, physical and psychological pain, agoraphobia, panic attacks, shame, internalised anger, depression, self-harm, genetic bewilderment, and generalised anxiety (Brodzinsky 25-47; Brodzinsky, Smith, & Brodzinsky 74; Kenny, Higgins, Soloff, & Sweid xiv; Levy-Shiff 97-98; Lifton 210-212; Verrier The Primal Wound 42-44; Wierzbicki 447-451) – including an all pervading sense of unreality experienced as dissociation (the experience of depersonalisation – where the self feels unreal – and derealisation – where the world feels unreal), disembodiment, and existential elision – all characteristics of Post Traumatic Stress Disorder (PTSD). In these ways, my body intervened, acted out, groaned in answer to the social overlay, and from beyond “the dermal veil” tried to procure access, as Vicky Kirby (77) writes, to “the body’s opaque ocean depths” through its illnesses, its eloquent, and incessantly aching and silent verbosities deepened and made impossibly fraught because I was not told. The aim of this paper is to discuss one aspect of how my body tried to channel the trauma of my secret fatality and liminality: my pre-disclosure art work (the cellular memory of my trauma also expressed itself, pre-disclosure, through my writings – poetry, journal entries – and also through post-coital glossolalia, all discussed at length in my Honours research “Womb Tongues” and my Doctoral Dissertation “The Womb Artist – A Novel: Translating Pre-verbal Late Discovery Adoption Trauma into Narrative”). From the age of thirty onwards I spent twelve years in therapy where the cause of my childhood and adult psychopathology remained a mystery. During this time, my embodied grief and memories found their way into my art work, a series of 5’ x 3’ acrylic paintings, some of which I offer now for discussion (figures 1-4). These paintings map and express what my body knew but could not verbalise (without language to express my grief, my body found other ways to vent). They are symptom and sign of my pre-verbal adoption trauma, evidence that my body ‘knew’ and laboured ceaselessly and silently to find creative ways to express the incarcerated trauma. Post disclosure, I have used my paintings as artefacts to inform, underpin, and nourish the writing of a collection of poetry “Womb Tongues” and a literary novel/memoir “The Womb Artist” (TWA) in an ongoing autoethnographical, performative, and critical inquiry. My practice-led research as a now conscious and creative witness, fashions the recontextualisation of my ‘self’ into my ‘self’ and society, this time with cognisant and reparative knowledge and facilitates the translation of my body’s psychopathology and memory (explicit and implicit) into a healing testimony that explores the traumatised body as text and politicizes the issues surrounding LDAs (Riley 205). If I use these paintings as a memoirist, I use them second hand, after the fact, after they have served their initial purpose, as the tangible art works of a baby buried beneath a culture’s prejudice, shame, and judgement and the personal cries from the illegitimate body/self. I use them now to explore and explain my subclinical and subterranean life as a LDA.My pre-disclosure paintings (Figures 1-4) – filled with vaginal, fetal, uterine, and umbilical references – provide some kind of ‘evidence’ that my body knew what had happened to me as if, with the tenacity of a poltergeist, my ‘spectral self’ found ways to communicate. Not simply clues, but the body’s translation of the intra-psychic landscape, a pictorial and artistic séance into the world, as if my amygdala – as quasar and signal, homing device and history lesson (a measure, container, and memoir) – knew how to paint a snap shot or an x-ray of the psyche, of my cellular marrow memories (a term formulated from fellow LDA Sandy McCutcheon’s (76) memoir, The Magician’s Son when he says, “What I really wanted was the history of my marrow”). If, as Salveet Talwar suggests, “trauma is processed from the body up”, then for the LDA pre-discovery, non-verbal somatic signage is one’s ‘mother tongue’(25). Talwar writes, “non-verbal expressive therapies such as art, dance, music, poetry and drama all activate the sub-cortical regions of the brain and access pre-verbal memories” (26). In these paintings, eerily divinatory and pointed traumatic, memories are made visible and access, as Gussie Klorer (213) explains in regard to brain function and art therapy, the limbic (emotional) system and the prefrontal cortex in sensorimotor integration. In this way, as Marie Angel and Anna Gibbs (168) suggest, “the visual image may serve as a kind of transitional mode in thought”. Ruth Skilbeck in her paper First Things: Reflections on Single-lens Reflex Digital Photography with a Wide-angled Lens, also discusses (with reference to her photographic record and artistic expression of her mother’s death) what she calls the “dark matter” – what has been overlooked, “left out”, and/or is inexplicable (55) – and the idea of art work as the “transitional object” as “a means that some artists use, conceptually and yet also viscerally, in response to the extreme ‘separation anxiety’ of losing a loved one, to the void of the Unknown” (57). In my case, non-disclosure prevented my literacy and the evolution of the image into language, prevented me from fully understanding the coded messages left for me in my art work. However, each of my paintings is now, with the benefit of full disclosure, a powerful, penetrating, and comprehensible intra and extra sensory cry from the body in kinaesthetic translation (Lusebrink, 125; Klorer, 217). In Figure 1, ‘Embrace’, the reference to the umbilical is palpable, described in my novel “The Womb Artist” (184) this way; “two ropes tightly entwine as one, like a dark and dirty umbilical cord snaking its way across a nether world of smudged umbers”. There is an ‘abject’ void surrounding it. The cord sapped of its colour, its blood, nutrients – the baby starved of oxygen, breath; the LDA starved of words and conscious understanding. It has two parts entwined that may be seen in many ways (without wanting to reduce these to static binaries): mother/baby; conscious/unconscious; first person/third person; child/adult; semiotic/symbolic – numerous dualities could be spun from this embrace – but in terms of my novel and of the adoptive experience, it reeks of need, life and death, a text choking on the poetic while at the same time nourished by it; a text made ‘available’ to the reader while at the same narrowing, limiting, and obscuring the indefinable nature of pre-verbal trauma. Figure 1. Embrace. 1993. Acrylic on canvas.The painting ‘Womb Tongues’ (Figure 2) is perhaps the last (and, obviously, lasting) memory of the infinite inchoate universe within the womb, the umbilical this time wrapped around in a phallic/clitorial embrace as the baby-self emerges into the constrictions of a Foucauldian world, where the adoptive script smothers the ‘body’ encased beneath the ‘coils’ of Judeo-Christian prejudice and centuries old taboo. In this way, the reassigned adoptee is an acute example of power (authority) controlling and defining the self and what knowledge of the self may be allowed. The baby in this painting is now a suffocated clitoris, a bound subject, a phallic representation, a gagged ‘tongue’ in the shape of the personally absent (but socially imposing) omni-present and punitive patriarchy. Figure 2. Womb Tongues. 1997. Acrylic on canvas.‘Germination’ (Figure 3) depicts an umbilical again, but this time as emerging from a seething underworld and is present in TWA (174) this way, “a colony of night crawlers that writhe and slither on the canvas, moving as one, dozens of them as thin as a finger, as long as a dream”. The rhizomic nature of this painting (and Figure 4), becomes a heaving horde of psychosomatic and psychopathological influences and experiences, a multitude of closely packed, intense, and dendridic compulsions and symptoms, a mass of interconnected (and by nature of the silence and lie) subterranean knowledges that force the germination of a ‘ghost baby/child/adult’ indicated by the pale and ashen seedling that emerges above ground. The umbilical is ghosted, pale and devoid of life. It is in the air now, reaching up, as if in germination to a psychological photosynthesis. There is the knot and swarm within the unconscious; something has, in true alien fashion, been incubated and is now emerging. In some ways, these paintings are hardly cryptic.Figure 3. Germination.1993. Acrylic on canvas.In Figure 4 ‘The Birthing Tree’, the overt symbolism reaches ‘clairvoyant status’. This could be read as the family ‘tree’ with its four faces screaming out of the ‘branches’. Do these represent the four babies relinquished by our mother (the larger of these ‘beings’ as myself, giving birth to the illegitimate, silenced, and abject self)? Are we all depicted in anguish and as wraithlike, grotesquely simplified into pure affect? This illegitimate self is painted as gestating a ‘blue’ baby, near full-term in a meld of tree and ‘self’, a blue umbilical cord, again, devoid of blood, ghosted, lifeless and yet still living, once again suffocated by the representation of the umbilical in the ‘bowels’ of the self, the abject part of the body, where refuse is stored and eliminated: The duodenum of the damned. The Devil may be seen as Christopher Bollas’s “shadow of the object”, or the Jungian archetypal shadow, not simply a Judeo-Christian fear-based spectre and curmudgeon, but a site of unprocessed and, therefore, feared psychological material, material that must be brought to consciousness and integrated. Perhaps the Devil also is the antithesis to ‘God’ as mother. The hell of ‘not mother’, no mother, not the right mother, the reluctant adoptive mother – the Devil as icon for the rich underbelly of the psyche and apophatic to the adopted/artificial/socially scripted self.Figure 4. The Birthing Tree. 1995. Acrylic on canvas.These paintings ache with the trauma of my relinquishment and LDA experience. They ache with my body’s truth, where the cellular and psychological, flesh and blood and feeling, leak from my wounds in unspeakable confluence (the two genital lips as the site of relinquishment, my speaking lips that have been sealed through non-disclosure and shame, the psychological trauma as Verrier’s ‘primal wound’) just as I leaked from my mother (and society) at birth, as blood and muck, and ooze and pus and death (Grosz 195) only to be quickly and silently mopped up and cleansed through adoption and life-long secrecy. Where I, as translator, fluent in both silence and signs, disclose the baby’s trauma, asking for legitimacy. My experience as a LDA sets up an interesting experiment, one that allows an examination of the pre-verbal/pre-disclosure body as a fleshed and breathing Rosetta Stone, as an interface between the language of the body and of the verbalised, painted, and written text. As a constructed body, written upon and invented legally, socially, and psychologically, I am, in Hélène Cixous’s (“To Live the Orange” 83) words, “un-forgetting”, “un-silencing” and “unearthing” my ‘self’ – I am re-writing, re-inventing and, under public scrutiny, legitimising my ‘self’. I am a site of inquiry, discovery, extrapolation, and becoming (Metta 492; Poulus 475) and, as Grosz (vii) suggests, a body with “all the explanatory power” of the mind. I am, as I embroider myself and my LDA experience into literary and critical texts, authoring myself into existence, referencing with particular relevance Peter Carnochan’s (361) suggestion that “analysis...acts as midwife to the birth of being”. I am, as I swim forever amorphous, invisible, and unspoken in my mother’s womb, fashioning a shore, landscaping my mind against the constant wet, my chronic liminality (Rambo 629) providing social landfall for other LDAs and silenced minorities. As Catherine Lynch (3) writes regarding LDAs, “Through the creation of text and theory I can formulate an intimate space for a family of adoptive subjects I might never know via our participation in a new discourse in Australian academia.” I participate through my creative, self-reflexive, process fuelled (Durey 22), practice-led enquiry. I use the intimacy (and also universality and multiplicity) and illegitimacy of my body as an alterative text, as a site of academic and creative augmentation in the understanding of LDA issues. The relinquished and silenced baby and LDA adult needs a voice, a ‘body’, and a ‘tender’ place in the consciousness of society, as Helen Riley (“Confronting the Conspiracy of Silence” 11) suggests, “voice, validation, and vindication”. Judith Herman (3) argues that, “Survivors challenge us to reconnect fragments, to reconstruct history, to make meaning of their present symptoms in the light of past events”. I seek to use the example of my experience – as Judith Durey (31) suggests, in “support of evocative, creative modes of representation as valid forms of research in their own right” – to unfurl the whole, to give impetus and precedence for other researchers into adoption and advocate for future babies who may be bought, sold, arranged, and/or created by various means. The recent controversy over Gammy, the baby boy born with Down Syndrome in Thailand, highlights the urgent and moral need for legislation with regard to surrogacy (see Kajsa Ekis Ekman’s Being and Being Bought: Prostitution, Surrogacy and the Split Self for a comprehensive examination of surrogacy issues). Indeed, Catherine Lynch in her paper Doubting Adoption Legislation links the experiences of LDAs and the children of born of surrogacy, most effectively arguing that, “if the fate that closed record adoptees suffered was a misplaced solution to the question of what to do with children already conceived how can you justify the deliberate conception of a child with the intention even before its creation of cruelly removing that child from their mother?” (6). Cixous (xxii) confesses, “All I want is to illustrate, depict fragments, events of human life and death...each unique and yet at the same time exchangeable. Not the law, the exception”. I, too, am a fragment, an illustration (a painting), and, as every individual always is – paradoxically – a communal and, therefore, deeply recognisable and generally applicable minority and exception. In my illegitimacy, I am some kind of evidence. Evidence of cellular memory. Evidence of embodiment. Evidence that silenced illegitimacies will manifest in symptom and non-verbal narratives, that they will ooze out and await translation, verification, and witness. This paper is offered with reverence and with feminist intention, as a revenant mouthpiece for other LDAs, babies born of surrogacy, and donor assisted offspring (and, indeed, any) who are marginalised, silenced, and obscured. It is also intended to promote discussion in the psychological and psychoanalytic fields and, as Helen Riley (202-207) advocates regarding late discovery offspring, more research within the social sciences and the bio-medical field that may encourage legislators to better understand what the ‘best interests of the child’ are in terms of late discovery of origins and the complexity of adoption/conception practices available today. As I write now (and always) the umbilical from my paintings curve and writhe across my soul, twist and morph into the swollen and throbbing organ of tongues, my throat aching to utter, my hands ready to craft latent affect into language in translation of, and in obedience to, my body’s knowledges. It is the art of mute witness that reverses genesis, that keeps the umbilical fat and supple and full of blood, and allows my conscious conception and creation. Indeed, in the intersection of my theoretical, creative, psychological, and somatic praxis, the heat (read hot and messy, insightful and insistent signage) of my body’s knowledges perhaps intensifies – with a ripe bouquet – the inevitably ongoing odour/aroma of the reproductive world. ReferencesAngel, Maria, and Anna Gibbs. “On Moving and Being Moved: The Corporeality of Writing in Literary Fiction and New Media Art.” Literature and Sensation, eds. Anthony Uhlmann, Helen Groth, Paul Sheehan, and Stephan McLaren. Newcastle upon Tyne, UK: Cambridge Scholars Publishing, 2009: 162-172. Bollas, Christopher. The Shadow of the Object: Psychoanalysis of the Unthought Known. New York: Columbia UP, 1987. Brodzinsky, David. “Adjustment to Adoption: A Psychosocial Perspective.” Clinical Psychology Review 7 (1987): 25-47. doi: 10.1016/0272-7358(87)90003-1.Brodzinsky, David, Daniel Smith, and Anne Brodzinsky. Children’s Adjustment to Adoption: Developmental and Clinical Issues. California: Sage Publications, 1998.Carnochan, Peter. “Containers without Lids”. Psychoanalytic Dialogues 16.3 (2006): 341-362.Cixous, Hélène. “To Live the Orange”. The Hélène Cixous Reader: With a Preface by Hélène Cixous and Foreword by Jacques Derrida, ed. Susan Sellers. Oxford, UK: Routledge, 1979/1994. 81-92. ---. “Preface.” The Hélène Cixous Reader: With a Preface by Hélène Cixous and Foreword by Jacques Derrida, ed. Susan Sellers. Oxford, UK: Routledge, 1994. xv-xxii.Coull, Kim. “Womb Tongues: A Collection of Poetry.” Honours Thesis. Perth, WA: Edith Cowan University, 2007. ---. “The Womb Artist – A Novel: Translating Late Discovery Adoptee Pre-Verbal Trauma into Narrative”. Dissertation. Perth, WA: Edith Cowan University, 2014. Durey, Judith. Translating Hiraeth, Performing Adoption: Art as Mediation and Form of Cultural Production. Dissertation. Perth, WA: Murdoch University, 2010. 22 Sep. 2011 .Ekis Ekman, Kajsa. Being and Being Bought: Prostitution, Surrogacy and the Split Self. Trans. S. Martin Cheadle. North Melbourne: Spinifex Press, 2013. Gardiner, Amanda. “Sex, Death and Desperation: Infanticide, Neonaticide, and Concealment of Birth in Colonial Western Australia”. Dissertation. Perth, WA: Edith Cowan University, 2014. Grosz, Elizabeth. Volatile Bodies. NSW: Allen &. Unwin, 1994. Grotevant, Harold D., Nora Dunbar, Julie K. Kohler, and Amy. M. Lash Esau. “Adoptive Identity: How Contexts within and beyond the Family Shape Developmental Pathways.” Family Relations 49.3 (2000): 79-87.Herman, Judith L. Trauma and Recovery: From Domestic Abuse to Political Terror. London: Harper Collins, 1992. Howard, Sethane, and Mark W. Crandall. Post Traumatic Stress Disorder: What Happens in the Brain. Washington Academy of Sciences 93.3 (2007): 1-18.Keneally, Thomas. Schindler’s List. London: Serpentine Publishing Company, 1982. Kenny, Pauline, Daryl Higgins, Carol Soloff, and Reem Sweid. Past Adoption Experiences: National Research Study on the Service Response to Past Adoption Practices. Research Report 21. Australian Institute of Family Studies, 2012.Kirby, Vicky. Telling Flesh: The Substance of the Corporeal. New York and London: Routledge, 1997. Klorer, P. Gussie. “Expressive Therapy with Severely Maltreated Children: Neuroscience Contributions.” Journal of the American Art Therapy Association 22.4 (2005): 213-220. doi:10.1080/07421656.2005.10129523.Levy-Shiff, Rachel. “Psychological Adjustment of Adoptees in Adulthood: Family Environment and Adoption-Related Correlates. International Journal of Behavioural Development 25 (2001): 97-104. doi: 1080/01650250042000131.Lifton, Betty J. “The Adoptee’s Journey.” Journal of Social Distress and the Homeless 11.2 (2002): 207-213. doi: 10.1023/A:1014320119546.Lusebrink, Vija B. “Art Therapy and the Brain: An Attempt to Understand the Underlying Processes of Art Expression in Therapy.” Journal of the American Art Therapy Association 21.3 (2004): 125-135. doi:10.1080/07421656. 2004.10129496.Lynch, Catherine. “An Ado/aptive Reading and Writing of Australia and Its Contemporary Literature.” Australian Journal of Adoption 1.1 (2009): 1-401.---. Doubting Adoption Legislation. n.d.McCutcheon, Sandy. The Magician’s Son: A Search for Identity. Sydney, NSW: Penguin, 2006. Metta, Marilyn. “Putting the Body on the Line: Embodied Writing and Recovery through Domestic Violence.” Handbook of Autoethnography, eds. Stacy Holman Jones, Tony Adams, and Carolyn Ellis. Walnut Creek, CA: Left Coast Press, 2013: 486-509.Pert, Candace. Molecules of Emotion: The Science behind Mind-body Medicine. New York: Touchstone, 2007. Rambo, Carol. “Twitch: A Performance of Chronic Liminality.” Handbook of Autoethnography, eds. Stacy Holman Jones, Tony Adams, and Carolyn Ellis. Walnut Creek, CA: Left Coast Press, 2013: 627-638.Riley, Helen J. Identity and Genetic Origins: An Ethical Exploration of the Late Discovery of Adoptive and Donor-insemination Offspring Status. Dissertation. Brisbane: Queensland University of Technology, 2012.---. “Confronting the Conspiracy of Silence and Denial of Difference for Late Discovery Persons and Donor Conceived People.” Australian Journal of Adoption 7.2 (2013): 1-13.Skilbeck, Ruth. “First Things: Reflection on Single-Lens Reflex Digital Photography with a Wide-Angle Lens.” International Journal of the Image 3 (2013): 55-66. Talwar, Savneet. “Accessing Traumatic Memory through Art Making: An Art Therapy Trauma Protocol (ATTP)." 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Photo by Alexander Grey on Unsplash ABSTRACT Current studies show that about half of transgender and gender-diverse (TGD) people wish to have children in the future. TGD patients who pursue gender-affirmation interventions must be aware of the impact that various treatments can have on fertility, as gender-affirming care through medical or surgical treatment can limit or alter reproductive potential. Many medical professional societies encourage providers to educate and counsel patients about the consequences of treatment and viable options for fertility preservation (FP) as early as possible, though patients may not be aware of all the family formation methods available. There is a significant need for a tool that thoroughly details not only the various opportunities for parenthood but the perceived cost, rates of success, and risks associated with each option. A fertility decision-aid would allow for a more robust informed consent process and shared decision-making for all individuals pursuing gender-affirming care. INTRODUCTION Over 1.6 million adults and youth in the United States, or about 0.6 percent of those age 13 and over, identify as transgender, according to a report released by The Williams Institute in June 2022.[1] Current studies show that approximately half of transgender and gender-diverse (TGD) people wish to have children in the future, which aligns with the rate of cisgender individuals who desire parenthood in some form.[2] Studies on parenthood show improved quality of life and mental health in TGD adults and decreased incidence of suicide in TGD women.[3] In one study, almost half of the TGD individuals who indicated an interest in parenthood said they wanted genetically related offspring.[4] However, medical or surgical therapies can limit reproductive potential.[5] Recent findings indicate that some TGD adults who underwent medical or surgical paths to affirmation regret decisions that may have led to their inability to have genetic children. Perhaps they did not know it was an option, faced barriers to care, or were not interested at the time.[6] Many medical professional societies, including the World Professional Association for Transgender Health (WPATH), the Endocrine Society, and the American College of Obstetrics and Gynecology, encourage providers to educate and counsel patients about the consequences of treatment and viable options for fertility preservation as early as possible.[7] This paper argues that TGD patients who pursue gender-affirmation interventions must be aware of the impact treatments can have on fertility and, ultimately, parenthood and that a design tool may help them understand the risks and make informed decisions. l. Gender Affirmation Options Some TGD individuals do not use medical or surgical therapies to feel affirmed in their identity.[8] Non-medical paths to affirmation include social and legal measures.[9] These reversible paths do not impact the individual’s future fertility potential. TGD individuals can follow different paths of gender-affirming care through social, legal, medical, and surgical affirmation.[10] Social affirmation can include using gender-affirming pronouns, names, and clothing.[11] Legal affirmation can include changing the gender and name on a birth certificate and other records in states where this is permissible.[12] Social and legal affirmations are reversible and do not impact fertility potential. Medical affirmation involves the use of gender-affirming hormone therapy. Feminizing or masculinizing hormone therapy allows for the development of secondary sex characteristics that more closely align with the individual's gender identity.[13] No set regimen for treatment exists, as a patient’s goals will determine their individualized plan.[14] Some standard feminizing agents include estrogen, androgen-reducing medications, and progestins, while the common masculinizing agent is testosterone.[15] Gender-affirming hormone therapy is not currently seen as a definitive cause of infertility, as it is possible to discontinue treatment and see a noted reversal of intended effects.[16] Research findings suggest that hormone therapy should stop for a minimum of three months to reverse any treatment effects.[17] The only available data on long-term hormonal therapy use is inconsistent, based on observational studies with varying duration and doses.[18] Individuals can stop gender-affirming hormone therapy, but its lasting impact on fertility is unknown.[19] A TGD individual may choose to undergo surgical interventions that do not impact fertility. These interventions can masculinize or feminize body parts to allow a patient’s physical appearance to align with their gender identity.[20] This care could include breast augmentation for TGD women and Adam’s apple reduction or breast reduction for TGD men.[21] Other surgical interventions will impact TGD individuals’ fertility. Genital surgery for a TGD woman can include the removal of the penis and scrotum (penectomy and orchiectomy) and the construction of a vagina and labia (vaginoplasty and valvuloplasty).[22] A TGD man can have removal of the ovaries and uterus (oophorectomy and hysterectomy) and construction of a penis and scrotum (metoidioplasty, phalloplasty, and scrotoplasty).[23] Following these gender-affirming surgeries, individuals are infertile due to the removal of their reproductive organs.[24] These procedures are irreversible and directly impact reproductive capacity in TGD individuals. ll. Fertility Counseling to Explain Paths to Parenthood Patients receiving gender-affirming care should have the opportunity to learn about the various ways to achieve parenthood, including fertility preservation. Family formation methods include sexual intercourse, artificial insemination, surrogacy, and adoption or foster care.[25] These methods apply to non-TGD people as well. Patients may not be aware of the various means of family-building, so accurate and expansive fertility counseling is essential before initiating medical or surgical affirming care. The frequency with which TGD individuals receive fertility counseling and how thorough it is, is unclear. When surveyed about fertility preservation, healthcare providers reported a lack of confidence in discussing fertility preservation with patients due to gaps in their knowledge on best practices, success rates, and regret rates in patients who did not preserve fertility. They also had varied perceptions of their role in treating patients and whether they should discuss family planning.[26] Patients have reported receiving an overview of fertility options from their primary transgender-healthcare providers before being referred to reproductive specialists.[27] While this is an essential step for patients seeking more information about their opportunities for parenthood, only 16 percent of Society for Assisted Reproductive Technology member clinics share information about options for transgender individuals on their websites.[28] Providers of transgender health care do not, and may not be trained to, provide adequate counsel to patients. Patients also cannot give informed consent for fertility or gender-affirming care interventions without more information on the benefits and burdens of all available treatments. Current literature demonstrates a need for a decision aid that thoroughly details not only the opportunities for parenthood but the perceived cost, rates of success, and risks associated with each option.[29] This tool could foster a more informed dialogue between an individual and their care team. A fertility decision aid would also allow for a more robust informed consent process for all individuals pursuing gender-affirming care. Regardless of the affirmation path chosen, a TGD individual should have early and frequent conversations with their care team regarding fertility. The World Professional Association for Transgender Health (WPATH) asserts that healthcare professionals should discuss fertility preservation options before initiating gender-affirming hormone therapy or surgery. The American College of Obstetrics and Gynecology states that “fertility and parenting desires should be discussed early in the process of transition, before the initiation of hormone therapy or gender affirmation surgery.”[30] The Endocrine Society writes that “all individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy in both adolescents and adults."[31] These conversations are essential even if the patient is not interested in parenthood at the time. WPATH addresses the potential for regret, as cases of individuals who received hormone therapy and genital surgery and later desired genetically related children have been identified.[32] TGD patients pursuing gender-affirming care should assess their individual fertility goals to better understand the many ways to build a family. Surveys of TGD adults show that participants want to become parents in various ways. In one study, 31.3 percent of those surveyed wanted to become parents through adoption, 25 percent wanted children through sexual intercourse, 15.6 percent through surrogacy, 12.5 percent using donor sperm, 9.4 percent using a known sperm donor, and 6.3 percent through the foster care system.[33] TGD women showed a significant interest in adoption (75 percent of participants), whereas more than half of TGD men wanted to become parents through sexual intercourse or pregnancy (58.3 percent).[34] These fertility goals should be acknowledged and discussed with the care team to guide decision-making about fertility preservation. lll. Fertility Preservation Individuals who wish to share their genetic makeup with their child will usually need to speak with a reproductive specialist about fertility preservation options. They are the same as those for cisgender individuals using fertility services before cancer treatment or elective preservation.[35] For TGD adults with ovaries, this includes freezing embryos (using donor or partner sperm) or ovarian tissue.[36] While no longer viewed as an experimental treatment, professionals offer tissue freezing to few patients due to a lack of data on its safety and efficacy.[37] For TGD adults with testicles, freezing sperm and preserving testicular tissue can preserve the ability to have biological children.[38] Fertility preservation numbers for TGD adults remain low. A study showed that 76.6 percent of TGD men and 76.1 percent of TGD women considered fertility preservation, but only 3.1 percent and 9.6 percent, respectively, initiated it.[39] Success rate, cost, need for travel, and elevated risk of gender dysphoria likely lead to lower use of fertility preservation.[40] According to the American Society for Reproductive Medicine, the average cost of an IVF cycle in the US is $12,400.[41] Intrauterine insemination can range in cost from a few hundred dollars to $2,000 per cycle.[42] There are also associated costs to freeze and store sperm and eggs.[43] Insurance coverage and physical location impact the costs and how the patient bears the costs.[44] For those who do not have sufficient or any insurance coverage, fertility preservation may not be feasible. Of additional significance for this population, fertility preservation techniques can exacerbate gender dysphoria as the patient must produce gametes associated with the gender they do not recognize.[45] For TGD women, masturbating in a clinical setting or sperm banking for sperm cryopreservation can cause severe distress.[46] Furthermore, fertility preservation for TGD men can be challenging and invasive. A transvaginal ultrasound exam is a requirement for the cryopreservation of embryos and oocytes.[47] This exam can cause significant distress as the procedure does not align with their male identity.[48] Controlled ovarian stimulation cycles require two weeks of daily gonadotropin injections, and the patient is given anesthesia for oocyte retrieval.[49] Furthermore, TGD men undergoing fertility preservation must discontinue testosterone use, and menstruation can resume.[50] lV. Other Paths to Parenthood a. Adoption TGD adults can also pursue parenthood through adoption systems, though foster care is a temporary option. While almost one-third of surveyed TGD adults consider adoption a means to parenthood, cost and fear of discrimination can prevent them from following through.[51] TGD individuals have expressed a reluctance to pursue adoption due to the fear of discrimination by adoption agencies, attorneys, or families.[52] Nineteen states in the US allow child welfare agencies to refuse to provide services to LGBTQ+ families if it conflicts with the religious beliefs of the relevant people in the agency.[53] Nineteen states have no laws about discrimination during the adoption process based on sexual orientation or gender identity.[54] Only 29 states have statutory or regulatory protections against discrimination based on orientation and gender identity.[55] b. Surrogacy There are two types of surrogacies: traditional and gestational.[56] In traditional surrogacy, professionals fertilize the surrogate’s egg by the sperm of an intended parent or a sperm donor through intrauterine insemination. In gestational surrogacy, the surrogate undergoes IVF to implant the fertilized embryo.[57] Egg donation can be used for gestational surrogacy if necessary. Those considering surrogacy need to understand the specific laws in their state, as they can differ significantly.[58] c. Intercourse TGD individuals who have not undergone genital surgery can have intercourse with the intention of causing pregnancy. TGD men who have not had genital surgery can bear children. For those who have initiated hormonal therapy, limited data has been collected on the impact of gender-affirming hormone therapy on conception.[59] TGD men have gotten pregnant after discontinuing testosterone use.[60] TGD women who have not had genital surgery can have intercourse with a person with ovaries and produce sperm to fertilize an egg. Gender-affirming hormone therapy possibly affects sperm viability.[61] V. A Decision Aid to Support Informed Consent and Shared Decision Making For individuals pursuing gender-affirming care, time is of the essence when considering fertility preservation. In one review, transgender health doctors reported that most patients did not want to postpone treatment for fertility preservation procedures, even if they wanted children;[62] any delay in treatment can be distressing for those with gender dysphoria.[63] Providers face several challenges when counseling patients about fertility. The WPATH guidelines pose an ethical dilemma for transgender health providers as limited data offers guidance about discussing fertility risks and recommendations with patients.[64] For TGD patients, limited and contradictory data about fertility outcomes before, during, and after gender affirmation exists, particularly for the lasting impact of gender-affirming hormone therapy.[65] For TGD women who have taken estrogen and stopped to pursue fertility preservation, data on sperm quality is mixed.[66] The data on when normal ovarian function resumes is variable for TGD men using testosterone who have stopped to pursue fertility preservation.[67] Much data comes from the oncofertility literature, which indicates that when providers use standardized counseling practices when discussing fertility with their patients, more patients undergo fertility preservation, and patient satisfaction increases.[68] For individuals seeking gender-affirming care, there is a need for a decision aid that providers can utilize across multiple clinics and programs.[69],[70] Patients must be aware of the benefits, risks, and alternatives of any intervention to provide truly informed consent. When discussing fertility for TGD patients, this includes which fertility options are available at each stage of transition and the potential for a live birth with each option.[71] Furthermore, a decision aid would allow for shared decision-making, where the patient is an active participant and co-designer of their treatment plan.[72] Shared decision-making acknowledges the healthcare provider’s beneficence, knowledge, and experience while equally valuing the right to patient autonomy and respecting the ability of the patient to inform the provider.[73] A decision aid can help initiate the conversations between a patient and their provider that allow for a true partnership in decision-making. A recent study investigated the efficacy and impact of a web-based fertility decision aid targeted at TGD adolescents and young adults.[74] This tool, titled Aid for Fertility-Related Medical Decisions (AFFRMED), significantly increased fertility knowledge in both youth and their parents while improving youth’s perceived ability to make fertility decisions.[75] Youth participants and their parents found the tool “feasible, acceptable, and usable.”[76] This initial study was small, with only eight adolescents or young adults and seven parents participating.[77] At large, the effectiveness of the trial will be the next step in determining the legitimacy of the aid for clinical use.[78] A similar decision-making tool designed for TGD adults would also be useful. The tool can present an average range of expected costs as much variability exists and costs change over time. This tool should also include general information on what is required to pursue each path to parenthood. For example, a patient undergoing fertility preservation needs to know what steps are necessary after the cryopreservation of gametes for live birth.[79] CONCLUSION Individuals pursuing gender-affirming care must closely consider the impact of their medical and surgical care on their desire to become parents as early in their affirmation journey as possible. A decision aid can be helpful if it outlines the risks to fertility and options to preserve fertility, with the specific data necessary to make an informed choice. The tool should include the methods of fertility preservation, each step of the protocol and respective risks for each method, the expected timeline from initiation to completion, general success rates, options for remaining gamete disposition, and the average cost of treatment. This should include a list of steps to initiate the process for each method and any potential barriers or obstacles. For surrogacy, the tool should include the two types and the average cost. For intercourse, the aid should include information on risks for discontinuing gender-affirming hormone therapy and general success rates. Clinics and providers could elect to tailor the decision aid for their population to include specific information about local laws and the availability of services. With a standardized fertility decision aid, TGD individuals can have a more thorough understanding of the opportunities and limitations placed on their reproductive capacity. Healthcare providers can feel more confident that their patients have access to relevant information regarding family-building before initiating medical or surgical affirmation. This allows for a more substantial informed consent and shared decision-making process, regardless of the decision made. A trial-tested decision-making tool for TGD adolescents and young adults exists that can serve as a model for creating aid for TGD adults of all ages. A fertility decision aid designed explicitly for TGD adults of reproductive age would be invaluable to support patients and healthcare providers in transgender health. - [1] Herman, J.L., Flores, A.R., O’Neill, K.K. (2022). How Many Adults and Youth Identify as Transgender in the United States? The Williams Institute, UCLA School of Law [2] Moravek M. B. (2019). Fertility preservation options for transgender and gender-nonconforming individuals. Current opinion in obstetrics & gynecology, 31(3), 170–176. https://doi.org/10.1097/GCO.0000000000000537 [3] Moravek (2019). [4] Moravek (2019). [5] Access to fertility services by transgender persons: an Ethics Committee opinion. (2015). Access to fertility services by transgender persons: an Ethics Committee opinion. Fertility and Sterility, 104(5), 1111–1115. https://doi.org/10.1016/j.fertnstert.2015.08.021 [6] Harris, R. M., Kolaitis, I. N., & Frader, J. E.. (2020). Ethical issues involving fertility preservation for transgender youth. Journal of Assisted Reproduction and Genetics, 37(10), 2453–2462. https://doi.org/10.1007/s10815-020-01873-9 [7] Bizic, M. R., Jeftovic, M., Pusica, S., Stojanovic, B., Duisin, D., Vujovic, S., Rakic, V., & Djordjevic, M. L. (2018). Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed research international, 2018, 9652305. https://doi.org/10.1155/2018/9652305 [8] Rafferty, J., COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, & SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS (2018). Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, 142(4), e20182162. https://doi.org/10.1542/peds.2018-2162 [9] Rafferty (2018). [10] Rafferty (2018). [11] Rafferty (2018). [12] Rafferty (2018). [13] Rafferty (2018). [14] WPATH (2012). [15] WPATH (2012). [16] Bizic (2018). [17] Bizic (2018). [18] Moravek (2019). [19] Finlayson, C., Johnson, E. K., Chen, D., Dabrowski, E., Gosiengfiao, Y., Campo-Engelstein, L., Rosoklija, I., Jacobson, J., Shnorhavorian, M., Pavone, M. E., Moravek, M. B., Bonifacio, H. J., Simons, L., Hudson, J., Fechner, P. Y., Gomez-Lobo, V., Kadakia, R., Shurba, A., Rowell, E., & Woodruff, T. K.. (2016). Proceedings of the Working Group Session on Fertility Preservation for Individuals with Gender and Sex Diversity. Transgender Health, 1(1), 99–107. https://doi.org/10.1089/trgh.2016.0008 [20] Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., & Hotaling, J. M.. (2019). Fertility concerns of the transgender patient. Translational Andrology and Urology, 8(3), 209–218. https://doi.org/10.21037/tau.2019.05.09 [21] Cheng (2019). [22] WPATH (2012). [23] WPATH (2012). [24] Bizic (2018). [25] Tornello, S. L., & Bos, H. (2017). Parenting Intentions Among Transgender Individuals. LGBT health, 4(2), 115–120. https://doi.org/10.1089/lgbt.2016.0153 [26] Sterling (2020). [27] Sterling (2020). [28] Sterling (2020). [29] Sterling (2020). [30] Health care for transgender and gender diverse individuals. ACOG Committee Opinion No. 823. American College of Obstetricians and Gynecologists. Obstet Gynecol 2021;137:e75–88. [31] Hembree (2017). [32] WPATH (2012). [33] Tornello (2017). [34] Tornello (2017). [35] Moravek (2019). [36] Wiesenthal (2022). [37] Choi, J. Y., & Kim, T. J.. (2022). Fertility Preservation and Reproductive Potential in Transgender and Gender Fluid Population. Biomedicines, 10(9), 2279. https://doi.org/10.3390/biomedicines10092279 [38] Wiesenthal (2022). [39] Mayhew (2020). [40] Sterling (2020). [41] American Society of Reproductive Medicine. (n.d.). Is in vitro fertilization expensive? In Vitro Fertilization (IVF). Retrieved November 28, 2022, from https://www.reproductivefacts.org/faqs/frequently-asked-questions-about-infertility/q06-is-in-vitro-fertilization-expensive/ [42] American Society of Reproductive Medicine. (n.d.). The difference between IUI and IVF - A patient education micro-video. Reproductive Facts. Retrieved November 20, 2022, from https://www.reproductivefacts.org/resources/educational-videos/videos/asrmsart-micro-videos/videos/the-difference-between-iui-and-ivf/ [43] Family Equality (2019). [44] Sterling (2020). [45] Bizic (2018). [46] Bizic (2018). [47] Choi (2022). [48] Bizic (2018). [49] Choi (2022). [50] Choi (2022). [51] Tornello (2017). [52] Brown, C.. (2021). Exploring trans people’s experiences of adoption and fostering in the United Kingdom: A qualitative study. International Journal of Transgender Health, 22(1-2), 89–100. https://doi.org/10.1080/26895269.2020.1867396 [53] Movement Advancement Project. "Equality Maps: Foster and Adoption Laws." https://www.lgbtmap.org/equality-maps/foster_and_adoption_laws. Accessed 10/28/2022. [54] Movement Advancement Project. “Equality Maps: Foster and Adoption Laws” (2022). [55] Movement Advancement Project. “Equality Maps: Foster and Adoption Laws” (2022). [56] Torres, G., Shapiro, A., & Mackey, T. K.. (2019). A review of surrogate motherhood regulation in south American countries: pointing to a need for an international legal framework. BMC Pregnancy and Childbirth, 19(1). https://doi.org/10.1186/s12884-019-2182-1 [57] Family building through gestational surrogacy. Committee Opinion No. 660. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e97–103. [58] Family building through gestational surrogacy (2016). [59] Light, A. D., Obedin-Maliver, J., Sevelius, J. M., & Kerns, J. L.. (2014). Transgender Men Who Experienced Pregnancy After Female-to-Male Gender Transitioning. Obstetrics & Gynecology, 124(6), 1120–1127. https://doi.org/10.1097/aog.0000000000000540 [60] Obedin-Maliver, J., & Makadon, H. J.. (2016). Transgender men and pregnancy. Obstetric Medicine, 9(1), 4–8. https://doi.org/10.1177/1753495x15612658 [61] Choi (2022). 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This article explores resilience as it is experienced by refugees in the context of a relational community, visiting the notions of trauma, a thicker description of resilience and the trajectory toward positive growth through community. It calls for going beyond a Western biomedical therapeutic approach of exploration and adopting more of an emic perspective incorporating the worldview of the refugees. The challenge is for service providers working with refugees (who have experienced trauma) to move forward from a ‘harm minimisation’ model of care to recognition of a facilitative, productive community of people who are in a transitional phase between homelands. Contextualising Trauma Prior to the 1980s, the term ‘trauma’ was not widely used in literature on refugees and refugee mental health, hardly existing as a topic of inquiry until the mid-1980’s (Summerfield 422). It first gained prominence in relation to soldiers who had returned from Vietnam and in need of medical attention after being traumatised by war. The term then expanded to include victims of wars and those who had witnessed traumatic events. Seahorn and Seahorn outline that severe trauma “paralyses you with numbness and uses denial, avoidance, isolation as coping mechanisms so you don’t have to deal with your memories”, impacting a person‘s ability to risk being connected to others, detaching and withdrawing; resulting in extreme loneliness, emptiness, sadness, anxiety and depression (6). During the Civil War in the USA the impact of trauma was referred to as Irritable Heart and then World War I and II referred to it as Shell Shock, Neurosis, Combat Fatigue, or Combat Exhaustion (Seahorn & Seahorn 66, 67). During the twenty-five years following the Vietnam War, the medicalisation of trauma intensified and Post Traumatic Stress Disorder (PTSD) became recognised as a medical-psychiatric disorder in 1980 in the American Psychiatric Association international diagnostic tool Diagnostic Statistical Manual (DSM–III). An expanded description and diagnosis of PTSD appears in the DSM-IV, influenced by the writings of Harvard psychologist and scholar, Judith Herman (Scheper-Hughes 38) The Diagnostic and Statistical Manual (DSM-IV) of Mental Disorders (American Psychiatric Association, 2000) outlines that experiencing the threat of death, injury to oneself or another or finding out about an unexpected or violent death, serious harm, or threat of the same kind to a family member or close person are considered traumatic events (Chung 11); including domestic violence, incest and rape (Scheper-Hughes 38). Another significant development in the medicalisation of trauma occurred in 1998 when the Victorian Foundation for Survivors of Torture (VFST) released an influential report titled ‘Rebuilding Shattered Lives’. This then gave clinical practice a clearer direction in helping people who had experienced war, trauma and forced migration by providing a framework for therapeutic work. The emphasis became strongly linked to personal recovery of individuals suffering trauma, using case management as the preferred intervention strategy. A whole industry soon developed around medical intervention treating people suffering from trauma related problems (Eyber). Though there was increased recognition for the medicalised discourse of trauma and post-traumatic stress, there was critique of an over-reliance of psychiatric models of trauma (Bracken, et al. 15, Summerfield 421, 423). There was also expressed concern that an overemphasis on individual recovery overlooked the socio-political aspects that amplify trauma (Bracken et al. 8). The DSM-IV criteria for PTSD model began to be questioned regarding the category of symptoms being culturally defined from a Western perspective. Weiss et al. assert that large numbers of traumatized people also did not meet the DSM-III-R criteria for PTSD (366). To categorize refugees’ experiences into recognizable, generalisable psychological conditions overlooked a more localized culturally specific understanding of trauma. The meanings given to collective experience and the healing strategies vary across different socio-cultural groupings (Eyber). For example, some people interpret suffering as a normal part of life in bringing them closer to God and in helping gain a better understanding of the level of trauma in the lives of others. Scheper-Hughes raise concern that the PTSD model is “based on a conception of human nature and human life as fundamentally vulnerable, frail, and humans as endowed with few and faulty defence mechanisms”, and underestimates the human capacity to not only survive but to thrive during and following adversity (37, 42). As a helping modality, biomedical intervention may have limitations through its lack of focus regarding people’s agency, coping strategies and local cultural understandings of distress (Eyber). The benefits of a Western therapeutic model might be minimal when some may have their own culturally relevant coping strategies that may vary to Western models. Bracken et al. document case studies where the burial rituals in Mozambique, obligations to the dead in Cambodia, shared solidarity in prison and the mending of relationships after rape in Uganda all contributed to the healing process of distress (8). Orosa et al. (1) asserts that belief systems have contributed in helping refugees deal with trauma; Brune et al. (1) points to belief systems being a protective factor against post-traumatic disorders; and Peres et al. highlight that a religious worldview gives hope, purpose and meaning within suffering. Adopting a Thicker Description of Resilience Service providers working with refugees often talk of refugees as ‘vulnerable’ or ‘at risk’ populations and strive for ‘harm minimisation’ among the population within their care. This follows a critical psychological tradition, what (Ungar, Constructionist) refers to as a positivist mode of inquiry that emphasises the predictable relationship between risk and protective factors (risk and coping strategies) being based on a ‘deficient’ outlook rather than a ‘future potential’ viewpoint and lacking reference to notions of resilience or self-empowerment (342). At-risk discourses tend to focus upon antisocial behaviours and appropriate treatment for relieving suffering rather than cultural competencies that may be developing in the midst of challenging circumstances. Mares and Newman document how the lives of many refugee advocates have been changed through the relational contribution asylum seekers have made personally to them in an Australian context (159). Individuals may find meaning in communal obligations, contributing to the lives of others and a heightened solidarity (Wilson 42, 44) in contrast to an individual striving for happiness and self-fulfilment. Early naturalistic accounts of mental health, influenced by the traditions of Western psychology, presented thin descriptions of resilience as a quality innate to individuals that made them invulnerable or strong, despite exposure to substantial risk (Ungar, Thicker 91). The interest then moved towards a non-naturalistic contextually relevant understanding of resilience viewed in the social context of people’s lives. Authors such as Benson, Tricket and Birman (qtd. in Ungar, Thicker) started focusing upon community resilience, community capacity and asset-building communities; looking at areas such as - “spending time with friends, exercising control over aspects of their lives, seeking meaningful involvement in their community, attaching to others and avoiding threats to self-esteem” (91). In so doing far more emphasis was given in developing what Ungar (Thicker) refers to as ‘a thicker description of resilience’ as it relates to the lives of refugees that considers more than an ability to survive and thrive or an internal psychological state of wellbeing (89). Ungar (Thicker) describes a thicker description of resilience as revealing “a seamless set of negotiations between individuals who take initiative, and an environment with crisscrossing resources that impact one on the other in endless and unpredictable combinations” (95). A thicker description of resilience means adopting more of what Eyber proposes as an emic approach, taking on an ‘insider perspective’, incorporating the worldview of the people experiencing the distress; in contrast to an etic perspective using a Western biomedical understanding of distress, examined from a position outside the social or cultural system in which it takes place. Drawing on a more anthropological tradition, intervention is able to be built with local resources and strategies that people can utilize with attention being given to cultural traditions within a socio-cultural understanding. Developing an emic approach is to engage in intercultural dialogue, raise dilemmas, test assumptions, document hopes and beliefs and explore their implications. Under this approach, healing is more about developing intelligibility through one’s own cultural and social matrix (Bracken, qtd. in Westoby and Ingamells 1767). This then moves beyond using a Western therapeutic approach of exploration which may draw on the rhetoric of resilience, but the coping strategies of the vulnerable are often disempowered through adopting a ‘therapy culture’ (Furedi, qtd. in Westoby and Ingamells 1769). Westoby and Ingamells point out that the danger is by using a “therapeutic gaze that interprets emotions through the prism of disease and pathology”, it then “replaces a socio-political interpretation of situations” (1769). This is not to dismiss the importance of restoring individual well-being, but to broaden the approach adopted in contextualising it within a socio-cultural frame. The Relational Aspect of Resilience Previously, the concept of the ‘resilient individual’ has been of interest within the psychological and self-help literature (Garmezy, qtd. in Wilson) giving weight to the aspect of it being an innate trait that individuals possess or harness (258). Yet there is a need to explore the relational aspect of resilience as it is embedded in the network of relationships within social settings. A person’s identity and well-being is better understood in observing their capacity to manage their responses to adverse circumstances in an interpersonal community through the networks of relationships. Brison, highlights the collective strength of individuals in social networks and the importance of social support in the process of recovery from trauma, that the self is vulnerable to be affected by violence but resilient to be reconstructed through the help of others (qtd. in Wilson 125). This calls for what Wilson refers to as a more interdisciplinary perspective drawing on cultural studies and sociology (2). It also acknowledges that although individual traits influence the action of resilience, it can be learned and developed in adverse situations through social interactions. To date, within sociology and cultural studies, there is not a well-developed perspective on the topic of resilience. Resilience involves a complex ongoing interaction between individuals and their social worlds (Wilson 16) that helps them make sense of their world and adjust to the context of resettlement. It includes developing a perspective of people drawing upon negative experiences as productive cultural resources for growth, which involves seeing themselves as agents of their own future rather than suffering from a sense of victimhood (Wilson 46, 258). Wilson further outlines the display of a resilience-related capacity to positively interpret and derive meaning from what might have been otherwise negative migration experiences (Wilson 47). Wu refers to ‘imagineering’ alternative futures, for people to see beyond the current adverse circumstances and to imagine other possibilities. People respond to and navigate their experience of trauma in unique, unexpected and productive ways (Wilson 29). Trauma can cripple individual potential and yet individuals can also learn to turn such an experience into a positive, productive resource for personal growth. Grief, despair and powerlessness can be channelled into hope for improved life opportunities. Social networks can act as protection against adversity and trauma; meaningful interpersonal relationships and a sense of belonging assist individuals in recovering from emotional strain. Wilson asserts that social capabilities assist people in turning what would otherwise be negative experiences into productive cultural resources (13). Graybeal (238) and Saleeby (297) explore resilience as a strength-based practice, where individuals, families and communities are seen in relation to their capacities, talents, competencies, possibilities, visions, values and hopes; rather than through their deficiencies, pathologies or disorders. This does not present an idea of invulnerability to adversity but points to resources for navigating adversity. Resilience is not merely an individual trait or a set of intrinsic behaviours that can be displayed in ‘resilient individuals’. Resilience, rather than being an unchanging attribute, is a complex socio-cultural phenomenon, a relational concept of a dynamic nature that is situated in interpersonal relations (Wilson 258). Positive Growth through a Community Based Approach Through migrating to another country (in the context of refugees), Falicov, points out that people often experience a profound loss of their social network and cultural roots, resulting in a sense of homelessness between two worlds, belonging to neither (qtd. in Walsh 220). In the ideological narratives of refugee movements and diasporas, the exile present may be collectively portrayed as a liminality, outside normal time and place, a passage between past and future (Eastmond 255). The concept of the ‘liminal’ was popularised by Victor Turner, who proposed that different kinds of marginalised people and communities go through phases of separation, ‘liminali’ (state of limbo) and reincorporation (qtd. in Tofighian 101). Difficulties arise when there is no closure of the liminal period (fleeing their former country and yet not being able to integrate in the country of destination). If there is no reincorporation into mainstream society then people become unsettled and feel displaced. This has implications for their sense of identity as they suffer from possible cultural destabilisation, not being able to integrate into the host society. The loss of social supports may be especially severe and long-lasting in the context of displacement. In gaining an understanding of resilience in the context of displacement, it is important to consider social settings and person-environment transactions as displaced people seek to experience a sense of community in alternative ways. Mays proposed that alternative forms of community are central to community survival and resilience. Community is a source of wellbeing for building and strengthening positive relations and networks (Mays 590). Cottrell, uses the concept of ‘community competence’, where a community provides opportunities and conditions that enable groups to navigate their problems and develop capacity and resourcefulness to cope positively with adversity (qtd. in Sonn and Fisher 4, 5). Chaskin, sees community as a resilient entity, countering adversity and promoting the well-being of its members (qtd. in Canavan 6). As a point of departure from the concept of community in the conventional sense, I am interested in what Ahmed and Fortier state as moments or sites of connection between people who would normally not have such connection (254). The participants may come together without any presumptions of ‘being in common’ or ‘being uncommon’ (Ahmed and Fortier 254). This community shows little differentiation between those who are welcome and those who are not in the demarcation of the boundaries of community. The community I refer to presents the idea as ‘common ground’ rather than commonality. Ahmed and Fortier make reference to a ‘moral community’, a “community of care and responsibility, where members readily acknowledge the ‘social obligations’ and willingness to assist the other” (Home office, qtd. in Ahmed and Fortier 253). Ahmed and Fortier note that strong communities produce caring citizens who ensure the future of caring communities (253). Community can also be referred to as the ‘soul’, something that stems out of the struggle that creates a sense of solidarity and cohesion among group members (Keil, qtd. in Sonn and Fisher 17). Often shared experiences of despair can intensify connections between people. These settings modify the impact of oppression through people maintaining positive experiences of belonging and develop a positive sense of identity. This has enabled people to hold onto and reconstruct the sociocultural supplies that have come under threat (Sonn and Fisher 17). People are able to feel valued as human beings, form positive attachments, experience community, a sense of belonging, reconstruct group identities and develop skills to cope with the outside world (Sonn and Fisher, 20). Community networks are significant in contributing to personal transformation. Walsh states that “community networks can be essential resources in trauma recovery when their strengths and potential are mobilised” (208). Walsh also points out that the suffering and struggle to recover after a traumatic experience often results in remarkable transformation and positive growth (208). Studies in post-traumatic growth (Calhoun & Tedeschi) have found positive changes such as: the emergence of new opportunities, the formation of deeper relationships and compassion for others, feelings strengthened to meet future life challenges, reordered priorities, fuller appreciation of life and a deepening spirituality (in Walsh 208). As Walsh explains “The effects of trauma depend greatly on whether those wounded can seek comfort, reassurance and safety with others. Strong connections with trust that others will be there for them when needed, counteract feelings of insecurity, hopelessness, and meaninglessness” (208). Wilson (256) developed a new paradigm in shifting the focus from an individualised approach to trauma recovery, to a community-based approach in his research of young Sudanese refugees. Rutter and Walsh, stress that mental health professionals can best foster trauma recovery by shifting from a predominantly individual pathology focus to other treatment approaches, utilising communities as a capacity for healing and resilience (qtd. in Walsh 208). Walsh highlights that “coming to terms with traumatic loss involves making meaning of the trauma experience, putting it in perspective, and weaving the experience of loss and recovery into the fabric of individual and collective identity and life passage” (210). Landau and Saul, have found that community resilience involves building community and enhancing social connectedness by strengthening the system of social support, coalition building and information and resource sharing, collective storytelling, and re-establishing the rhythms and routines of life (qtd. in Walsh 219). Bracken et al. suggest that one of the fundamental principles in recovery over time is intrinsically linked to reconstruction of social networks (15). This is not expecting resolution in some complete ‘once and for all’ getting over it, getting closure of something, or simply recovering and moving on, but tapping into a collective recovery approach, being a gradual process over time. Conclusion A focus on biomedical intervention using a biomedical understanding of distress may be limiting as a helping modality for refugees. Such an approach can undermine peoples’ agency, coping strategies and local cultural understandings of distress. Drawing on sociology and cultural studies, utilising a more emic approach, brings new insights to understanding resilience and how people respond to trauma in unique, unexpected and productive ways for positive personal growth while navigating the experience. This includes considering social settings and person-environment transactions in gaining an understanding of resilience. Although individual traits influence the action of resilience, it can be learned and developed in adverse situations through social interactions. Social networks and capabilities can act as a protection against adversity and trauma, assisting people to turn what would otherwise be negative experiences into productive cultural resources (Wilson 13) for improved life opportunities. The promotion of social competence is viewed as a preventative intervention to promote resilient outcomes, as social skill facilitates social integration (Nettles and Mason 363). As Wilson (258) asserts that resilience is not merely an individual trait or a set of intrinsic behaviours that ‘resilient individuals’ display; it is a complex, socio-cultural phenomenon that is situated in interpersonal relations within a community setting. References Ahmed, Sara, and Anne-Marie Fortier. “Re-Imagining Communities.” International of Cultural Studies 6.3 (2003): 251-59. Bracken, Patrick. J., Joan E. Giller, and Derek Summerfield. Psychological Response to War and Atrocity: The Limitations of Current Concepts. Elsevier Science, 1995. 8 Aug, 2013 ‹http://www.freedomfromtorture.org/sites/default/files/documents/Summerfield-PsychologicalResponses.pdf>. Brune, Michael, Christian Haasen, Michael Krausz, Oktay Yagdiran, Enrique Bustos and David Eisenman. “Belief Systems as Coping Factors for Traumatized Refugees: A Pilot Study.” Eur Psychiatry 17 (2002): 451-58. Canavan, John. “Resilience: Cautiously Welcoming a Contested Concept.” Child Care in Practice 14.1 (2008): 1-7. Chung, Juna. Refugee and Immigrant Survivors of Trauma: A Curriculum for Social Workers. Master’s Thesis for California State University. Long Beach, 2010. 1-29. Eastmond, Maria. “Stories of Lived Experience: Narratives in Forced Migration Research.” Journal of Refugee Studies 20.2 (2007): 248-64. Eyber, Carola “Cultural and Anthropological Studies.” In Forced Migration Online, 2002. 8 Aug, 2013. ‹http://www.forcedmigration.org/research-resources/expert-guides/psychosocial- issues/cultural-and-anthropological-studies>. Graybeal, Clay. “Strengths-Based Social Work Assessment: Transforming the Dominant Paradigm.” Families in Society 82.3 (2001): 233-42. Kleinman, Arthur. “Triumph or Pyrrhic Victory? The Inclusion of Culture in DSM-IV.” Harvard Rev Psychiatry 4 (1997): 343-44. Mares, Sarah, and Louise Newman, eds. Acting from the Heart- Australian Advocates for Asylum Seekers Tell Their Stories. Sydney: Finch Publishing, 2007. Mays, Vicki M. “Identity Development of Black Americans: The Role of History and the Importance of Ethnicity.” American Journal of Psychotherapy 40.4 (1986): 582-93. Nettles, Saundra Murray, and Michael J. Mason. “Zones of Narrative Safety: Promoting Psychosocial Resilience in Young People.” The Journal of Primary Prevention 25.3 (2004): 359-73. Orosa, Francisco J.E., Michael Brune, Katrin Julia Fischer-Ortman, and Christian Haasen. “Belief Systems as Coping Factors in Traumatized Refugees: A Prospective Study.” Traumatology 17.1 (2011); 1-7. Peres, Julio F.P., Alexander Moreira-Almeida, Antonia, G. Nasello, and Harold, G. Koenig. “Spirituality and Resilience in Trauma Victims.” J Relig Health (2006): 1-8. Saleebey, Dennis. “The Strengths Perspective in Social Work Practice: Extensions and Cautions.” Social Work 41.3 (1996): 296-305. Scheper-Hughes, Nancy. “A Talent for Life: Reflections on Human Vulnerability and Resilience.” Ethnos 73.1 (2008): 25-56. Seahorn, Janet, J. and Anthony E. Seahorn. Tears of a Warrior. Ft Collins, USA: Team Pursuits, 2008. Sonn, Christopher, and Adrian Fisher. “Sense of Community: Community Resilient Responses to Oppression and Change.” Unpublished article. Curtin University of Technology & Victoria University of Technology: undated. Summerfield, Derek. “Childhood, War, Refugeedom and ‘Trauma’: Three Core Questions for Medical Health Professionals.” Transcultural Psychiatry 37.3 (2000): 417-433. Tofighian, Omid. “Prolonged Liminality and Comparative Examples of Rioting Down Under”. Fear and Hope: The Art of Asylum Seekers in Australian Detention Centres Literature and Aesthetics (Special Edition) 21 (2011): 97-103. Ungar, Michael. “A Constructionist Discourse on Resilience: Multiple Contexts, Multiple Realities Among at-Risk Children and Youth.” Youth Society 35.3 (2004): 341-365. Ungar, Michael. “A Thicker Description of Resilience.” The International Journal of Narrative Therapy and Community Work 3 & 4 (2005): 85-96. Walsh, Froma. “Traumatic Loss and Major Disasters: Strengthening Family and Community Resilience.” Family Process 46.2 (2007): 207-227. Weiss, Daniel. S., Charles R. Marmar, William. E. Schlenger, John. A. Fairbank, Kathleen Jordon, Richard L. Hough, and Richard A. Kulka. “The Prevalence of Lifetime and Partial Post- Traumatic Stress Disorder in Vietnam Theater Veterans.” Journal of Traumatic Stress 5.3 (1992):365-76. Westoby, Peter, and Ann Ingamells. “A Critically Informed Perspective of Working with Resettling Refugee Groups in Australia.” British Journal of Social Work 40 (2010): 1759-76. Wilson, Michael. “Accumulating Resilience: An Investigation of the Migration and Resettlement Experiences of Young Sudanese People in the Western Sydney Area.” PHD Thesis. University of Western Sydney ( 2012): 1-297. Wu, K. M. “Hope and World Survival.” Philosophy Forum 12.1-2 (1972): 131-48.

“The intellect must not only desire surreptitious delights; it must become completely free and celebrate Saturnalia.” (Nietzsche 6) Theory-jamming suggests an array of eclectic methods, deployed in response to emerging conditions, using traditional patterns to generate innovative moves, seeking harmony and syncopation, transparent about purpose and power, aiming for demonstrable certainties while aware of their own provisional fragility. In this paper, theory-jamming is suggested as an antidote for the confusion and disarray that typifies communication theory. Communication theory as the means to conceptualise the transmission of information and the negotiation of meaning has never been a stable entity. Entrenched divisions between ‘administrative’ and ‘critical’ tendencies are played out within schools and emerging disciplines and across a range of scientific/humanist, quantitative/qualitative and political/cultural paradigms. “Of course, this is only the beginning of the mischief for there are many other polarities at play and a host of variations within polar contrasts” (Dervin, Shields and Song). This paper argues that the play of contending schools with little purchase on each other, or anything much, has turned meta-discourse about communication into an ontological spiral. Perhaps the only way to ride out this storm is to look towards communication practices that confront these issues and appreciate their theoretical underpinnings. From its roots in jazz and blues to its contemporary manifestations in rap and hip-hop and throughout the communication industries, the jam (or improvised reorganisation of traditional themes into new and striking patterns) confronts the ontological spiral in music, and life, by taking the flotsam flung out of the spiral to piece together the means to transcend the downward pull into the abyss. Many pretenders have a theory. Theory abounds: language theory, number theory, game theory, quantum theory, string theory, chaos theory, cyber-theory, queer theory, even conspiracy theory and, most poignantly, the putative theory of everything. But since Bertrand Russell’s unsustainable class of all classes, Gödel’s systemically unprovable propositions and Heisenberger’s uncertainty principle, the propensity for theories to fall into holes in themselves has been apparent. Nowhere is this more obvious than in communication theory where many schools contend without actually connecting to each other. From the 1930s, as the mass media formed, there have been administrative and critical tendencies at war in the communication arena. Some point to the origins of the split in the Institute of Social Research’s Radio Project where pragmatic sociologist, Paul Lazarsfeld broke with Frankfurt School critical theorist, Theodor Adorno over the quality of data. Lazarsfeld was keen to produce results while Adorno complained the data over-simplified the relationship between mass media and audiences (Rogers). From this split grew the twin disciplines of mass communication (quantitative, liberal, commercial and lost in its obsession with the measurement of minor media effects) and cultural/media studies (qualitative, post-Marxist, radical and lost in simulacra of their own devising). The complexity of interactions between these two disciplines, with the same subject matter but very different ways of thinking about it, is the foundation of the ontological black hole in communication theory. As the disciplines have spread out across universities, professional organizations and publishers, they have been used and abused for ideological, institutional and personal purposes. By the summer of 1983, the split was documented in a special issue of the Journal of Communication titled “Ferment in the Field”. Further, professional courses in journalism, public relations, marketing, advertising and media production have complex relations with both theoretical wings, which need the student numbers and are adept at constructing and defending new boundaries. The 90s saw any number ‘wars’: Journalism vs Cultural Studies, Cultural Studies vs Cultural Policy Studies, Cultural Studies vs Public Relations, Public Relations vs Journalism. More recently, the study of new communication technologies has led to a profusion of nascent, neo-disciplines shadowing, mimicking and reacting with old communication studies: “Internet studies; New media studies; Digital media studies; Digital arts and culture studies; Cyberculture studies; Critical cyberculture studies; Networked culture studies; Informatics; Information science; Information society studies; Contemporary media studies” (Silver & Massanari 1). As this shower of cyberstudies spirals by, it is further warped by the split between the hard science of communication infrastructure in engineering and information technology and what the liberal arts have to offer. The early, heroic attempt to bridge this gap by Claude Shannon and, particularly, Warren Weaver was met with disdain by both sides. Weaver’s philosophical interpretation of Shannon’s mathematics, accommodating the interests of technology and of human communication together, is a useful example of how disparate ideas can connect productively. But how does a communications scholar find such connections? How can we find purchase amongst this avalanche of ideas and agendas? Where can we get the traction to move beyond twentieth century Balkanisation of communications theory to embrace the whole? An answer came to me while watching the Discovery Channel. A documentary on apes showed them leaping from branch to branch, settling on a swaying platform of leaves, eating and preening, then leaping into the void until they make another landing, settling again… until the next leap. They are looking for what is viable and never come to ground. Why are we concerned to ground theory which can only prove its own impossibility while disregarding the certainty of what is viable for now? I carried this uneasy insight for almost five years, until I read Nietzsche on the methods of the pre-Platonic philosophers: “Two wanderers stand in a wild forest brook flowing over rocks; the one leaps across using the stones of the brook, moving to and fro ever further… The other stands there helplessly at each moment. At first he must construct the footing that can support his heavy steps; when this does not work, no god helps him across the brook. Is it only boundless rash flight across great spaces? Is it only greater acceleration? No, it is with flights of fantasy, in continuous leaps from possibility to possibility taken as certainties; an ingenious notion shows them to him, and he conjectures that there are formally demonstrable certainties” (Nietzsche 26). Nietzsche’s advice to take the leap is salutary but theory must be more than jumping from one good idea to the next. What guidance do the practices of communication offer? Considering new forms that have developed since the 1930s, as communication theory went into meltdown, the significance of the jam is unavoidable. While the jam session began as improvised jazz and blues music for practice, fellowship and fun, it quickly became the forum for exploring new kinds of music arising from the deconstruction of the old and experimentation with technical, and ontological, possibilities. The jam arose as a spin-off of the dance music circuit in the 1930s. After the main, professional show was over, small groups would gather together in all-night dives for informal, spontaneous sessions of unrehearsed improvisation, playing for their own pleasure, “in accordance with their own esthetic [sic] standards” (Cameron 177). But the jam is much more than having a go. The improvisation occurs on standard melodies: “Theoretically …certain introductions, cadenzas, clichés and ensemble obbligati assume traditional associations (as) ‘folkways’… that are rarely written down but rather learned from hearing (“head jobs”)” (Cameron 178-9). From this platform of tradition, the artist must “imagine in advance the pattern which unfolds… select a part in the pattern appropriate to the occasion, instrument and personal abilities (then) produce startlingly distinctive sound patterns (that) rationalise the impossible.” The jam is founded on its very impossibility: “the jazz aesthetic is basically a paradox… traditionalism and the radical originality are irreconcilable” (Cameron 181). So how do we escape from this paradox, the same paradox that catches all communication theorists between the demands of the past and the impossibility of the future? “Experimentation is mandatory and formal rules become suspect because they too quickly stereotype and ossify” (Cameron 181). The jam seems to work because it offers the possibility of the impossible made real by the act of communication. This play between the possible and the impossible, the rumbling engine of narrative, is the dynamo of the jam. Theory-jamming seeks to activate just such a dynamo. Rather than having a group of players on their instruments, the communication theorist has access a range of theoretical riffs and moves that can be orchestrated to respond to the question in focus, to latest developments, to contradictions or blank spaces within theoretical terrains. The theory-jammer works to their own standards, turning ideas learned from others (‘head jobs’) into their own distinctive patterns, still reliant on traditional melody, harmony and syncopation but now bent, twisted and reorganised into an entirely new story. The practice of following old pathways to new destinations has a long tradition in the West as eclecticism, a Graeco-Roman, particularly Alexandrian, philosophical tradition from the first century BC to the end of the classical period. Typified by Potamo who “encouraged his pupils instead to learn from a variety of masters”, eclecticism sought the best from each school, “all that teaches righteousness combined, the complete eclectic unity” (Kelley 578). By selecting the best, most reasonable, most useful elements from existing philosophical beliefs, polymaths such as Cicero sought the harmonious solution of particular problems. We see something similar to eclecticism in the East in the practices of ‘wild fox zen’ which teaches liberation from conceptual fixation (Heine). The 20th century’s most interesting eclectic was probably Walter Benjamin whose method owes something to both scientific Marxism and the Jewish Kabbalah. His hero was the rag-picker who had the cunning to create life from refuse and detritus. Benjamin’s greatest work, the unfinished Arcades Project, sought to create history from the same. It is a collection of photos, ephemera and transcriptions from books and newspapers (Benjamin). The particularity of eclecticism may be contrasted with the claim to universality of syncretism, the reconciliation of disparate or opposing beliefs by melding together various schools of thought into a new orthodoxy. Theory-jammers are not looking for a final solution but rather they seek what will work on this problem now, to come to a provisional solution, always aware that other, better, further solutions may be ahead. Elements of the jam are apparent in other contemporary forms of communication. For example bricolage, the practice from art, culture and information systems, involves tinkering elements together by trial and error, in ways not originally planned. Pastiche, from literature to the movies, mimics style while creating a new message. In theatre and TV comedy, improvisation has become a style in itself. Theory-jamming has direct connections with brainstorming, the practice that originated in the advertising industry to generate new ideas and solutions by kicking around possibilities. Against the hyper-administration of modern life, as the disintegration of grand theory immobilises thinkers, theory-jamming provides the means to think new thoughts. As a political activist and communications practitioner in Australia over the last thirty years, I have always been bemused by the human propensity to factionalise. Rather than getting bogged down by positions, I have sought to use administrative structures to explore critical ideas, to marshal critical approaches into administrative apparatus, to weld together critical and administrative formations in ways useful to both sides, bust most importantly, in ways useful to human society and a healthy environment. I've been accused of selling-out by the critical camp and of being unrealistic by the administrative side. My response is that we have much more to learn by listening and adapting than we do by self-satisfied stasis. Five Theses on Theory-Jamming Eclecticism requires Ethnography: the eclectic is the ethnographer loose in their own mind. “The free spirit surveys things, and now for the first time mundane existence appears to it worthy of contemplation…” (Nietzsche 6). Enculturation and Enumeration need each other: qualitative and quantitative research work best when they work off each other. “Beginners learned how to establish parallels, by means of the Game’s symbols, between a piece of classical music and the formula for some law of nature. Experts and Masters of the Game freely wove the initial theme into unlimited combinations.” (Hesse) Ephemera and Esoterica tell us the most: the back-story is the real story as we stumble on the greatest truths as if by accident. “…the mind’s deeper currents often need to be surprised by indirection, sometimes, indeed, by treachery and ruse, as when you steer away from a goal in order to reach it more directly…” (Jameson 71). Experimentation beyond Empiricism: more than testing our sense of our sense data of the world. Communication theory extends from infra-red to ultraviolet, from silent to ultrasonic, from absolute zero to complete heat, from the sub-atomic to the inter-galactic. “That is the true characteristic of the philosophical drive: wonderment at that which lies before everyone.” (Nietzsche 6). Extravagance and Exuberance: don’t stop until you’ve got enough. Theory-jamming opens the possibility for a unified theory of communication that starts, not with a false narrative certainty, but with the gaps in communication: the distance between what we know and what we say, between what we say and what we write, between what we write and what others read back, between what others say and what we hear. References Benjamin, Walter. The Arcades Project. Cambridge, Mass: Harvard UP, 2002. Cameron, W. B. “Sociological Notes on the Jam Session.” Social Forces 33 (Dec. 1954): 177–82. Dervin, B., P. Shields and M. Song. “More than Misunderstanding, Less than War.” Paper at International Communication Association annual meeting, New York City, NY, 2005. 5 Oct. 2006 http://www.allacademic.com/meta/p13530_index.html>. “Ferment in the Field.” Journal of Communication 33.3 (1983). Heine, Steven. “Putting the ‘Fox’ Back in the ‘Wild Fox Koan’: The Intersection of Philosophical and Popular Religious Elements in The Ch’an/Zen Koan Tradition.” Harvard Journal of Asiatic Studies 56.2 (Dec. 1996): 257-317. Hesse, Hermann. The Glass Bead Game. Harmondsworth: Penguin, 1972. Jameson, Fredric. “Postmodernism, or the Cultural Logic of Late Capitalism.” New Left Review 146 (1984): 53-90. Kelley, Donald R. “Eclecticism and the History of Ideas.” Journal of the History of Ideas 62.4 (Oct. 2001): 577-592 Nietzsche, Friedrich. The Pre-Platonic Philosophers. Urbana: University of Illinois Press, 2001. Rogers, E. M. “The Empirical and the Critical Schools of Communication Research.” Communication Yearbook 5 (1982): 125-144. Shannon, C.E., and W. Weaver. The Mathematical Theory of Communication. Urbana: University of Illinois Press, 1949. Silver, David, Adrienne Massanari. Critical Cyberculture Studies. New York: NYU P, 2006. Citation reference for this article MLA Style Stockwell, Stephen. "Theory-Jamming: Uses of Eclectic Method in an Ontological Spiral." M/C Journal 9.6 (2006). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0612/09-stockwell.php>. APA Style Stockwell, S. (Dec. 2006) "Theory-Jamming: Uses of Eclectic Method in an Ontological Spiral," M/C Journal, 9(6). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0612/09-stockwell.php>.

Introduction Many years ago, the moral fable of Pinocchio warned children about the evils of lying (Perella). This article explores how children are learning lie-related insights from genres of currently marketed polygraph-style “spy kits”, voice stress analysis apps, and electric shock-delivering games. These artifacts are emerging despite the fact that polygraphy and other lie detection approaches are restricted in use in certain business and community contexts, in part because of their dubious scientific support. However, lie detection devices are still applied in many real-life settings, often in critically important security, customs, and employment arenas (Bunn). A commonly accepted definition of the term “lie” is “a successful or unsuccessful deliberate attempt, without forewarning, to create in another a belief which the communicator considers to be untrue” (Vrij 15), which includes the use of lies in various gaming situations. Many children’s games involve some kind of deception, and mental privacy considerations are important in many social contexts (such as “keeping a poker face”). The dystopian scenario of children learning basic honesty notions through technologically-enabled lie detection games scripted by corporate developers presents frightening prospects. These lie detection toys and games impart important moral perspectives through technological and algorithmic means (including electrical shocks and online shaming) rather than through human modelling and teaching. They normalise and lessen the seriousness of lying by reducing it into a game. In this article I focus on United States and United Kingdom toys and games, but comparable lie detection approaches have permeated other nations and cultures. Alder characterises the US as having an “obsession” with lie detection devices (1), an enthusiasm increasingly shared with other nations. Playing with the Truth: Spy Kits, Voice Stress Apps, and Shocking Liar The often-frightening image of an individual strapped to sensors and hooked up to a polygraph is often found in movies, television shows, and social media (Littlefield). I construe the notion of “lie detection” as “the use of a physiological measurement apparatus with the explicit aim of identifying when someone is lying. This typically comes with specific protocols for questioning the subject, and the output is graphically represented” (Bergers 1). Some lie detection toys utilise autonomic or unintentionally-supplied input in their analyses (such as the vocal changes related to stress); with networked toys, the data can subsequently be utilised by third parties. These aspects raise questions concerning consent as well as the validity of the results. Developers are producing related artifacts that challenge the difference between truth and lies, such as robots that “lie” by giving children responses to questions based on the children’s analysed preferences rather than standard determinations of truth and falsity (Zhu). Early lie detection games for children include the 1961 Lie Detecto from Manning Manufacturing. The technologies involved are galvanometers that required a 9-volt battery to operate, and sensors strapped to the hands of the subjects. It was reportedly designed “for junior G-men”, with suggested test questions for subjects such as "Do you like school?" Its ratings included "Could Be" and "Big Whopper" (“TIME’s New Products”). Lie detection had also been projected as fertile ground for children’s own educational research ventures. For example, in 2016 the popular magazine Scientific American outlined how young people could conduct experiments as to whether cognitive load (such as working on complex puzzles) affects the subject’s galvanic input to lie detection devices (Science Buddies). However, the Science Buddies’ description of the proposed activity did not encourage children to question the validity of the device itself. In organisational and agency settings, polygraph-style strategies are generally labour-intensive, involving experts who set up and administer tests (Bunn). These resource-intensive aspects of polygraphs may make their use in games attractive to players who want theatrical scripts to act out particular roles. An example of a lie detection toy that models the polygraph is the currently marketed Discovery Kids’ Electronic Lie Detection Portable Spy Kit, in which children go through the procedures of attaching the polygraph’s sensors to a human subject (Granich). The roles of “spy” and “detective” are familiar ones in many children’s books and movies, so the artifacts involved fit readily into children’s narratives. However, the overall societal importance of what they are modelling may still be beyond children’s grasps. Users of the comparable spy kit Project MC2 are given the following characterisation of their lie detection device, designed for individuals aged 6 and older: When someone lies, his or her body often produces small reactions from being nervous or stressed. One of those reactions is a small release of sweat. That moisture increases the skin’s electrical conductivity, or galvanic skin response, and the lie detector reads it as a fib. That's why the lie detector’s clips go on the fingers, because there are lots of sweat glands in your hands. Product includes: Lie detector, disguised as a mint box with a hidden button to force a truth or lie. Equipped with indicator light and sounds. Neon-colored wires with finger clips. (“Project MC2”) Similar sorts of lie detection approaches (though more sophisticated) are currently being used in US military operations. For example, the US Army’s Preliminary Credibility Assessment Screening Systems (PCASS) are handheld polygraphs designed for use in battle. Voice stress analysis systems for lie detection have been used for decades in business as well as medical and crime contexts. As described by Price, the US toy maker Hasbro distributes The Lie Detector Game, which “uses voice analysis to determine whether someone is lying”. In the box you’ll get a lie detector device and 64 cards with questions to answer as part of the gameplay … . If you tell the truth, or the device at least thinks you did, then you score a point. Lying loses you a point” (1). An assortment of smartphone apps with voice-stress analysis capabilities designed for lie detection are also widely available along with suggestions for their use in games (McQuarrie), providing yet another way for children to explore truth and deception in technologically-framed contexts. Lie detection devices for entertainment generally construe at least one of the participants in the toy’s or game’s operations as a “subject”. The Shocking Liar game openly entices users to construct the human game players as “victims”: The SHOCKING LIAR [sic] is a table top device that you strap your victim's hand to, delivering a small electric shock when it thinks a lie is being told… The lie detector evaluates the data and stores the information after each question giving an accumulation of data on the person being questioned. This means the more questions that you ask, the more information the lie detector has to evaluate... Place your hand onto the hand plate of the SHOCKING LIAR. If you tell the truth, you can move away from it safely and if you tell a direct lie or have given an unacceptable amount of half-truths, you will receive an electric shock. Children who use Shocking Liar are indeed led to assume that they can catch themselves or friends in dishonesty, but research justification for the Shocking Liar’s results is not available. The societal messages imparted by the toys to children (such as “this toy can determine whether you are lying”) make their impacts especially consequential. These toys and games extract from the subjects’ data various aspects of which the subjects may not have conscious control or even awareness. For instance, the pitch of the subject’s voice can be mined and subsequently given voice stress analysis, as in the previously described Hasbro game. From this “shadow” or autonomic input is developed an interpretation (however problematic) of the subjects’ mental state. The results of the analysis may eventually be processed consciously by subjects, either as polygraph readings or electrical shocks (as in Shocking Liar). The autonomic input involved is often known as “leakage” or “tells” (Ekman). Game playing with robots presents new lie detection venues. Children often react differently in robot-mediated interactions to truth and deception issues than they do with human beings (Pearson). Since the opportunities for child-robot interaction are increasing with the advent of companion robots, new contexts for lie detection games are emerging. Robots that present verbal feedback to children based on the child’s preferences over time, or that strategically withhold information, are being developed and marketed. Research on children’s responses to robots may provide clues as to how to make cognitive engineering and mental privacy invasions more acceptable. This raises serious concerns about children’s perceptions of the standings of robots as moral guides as well as gaming companions. For younger children who are just acquiring the notion of lying, the toys and games could extend the kinds of socialisation provided by their parents and guardians. As lie detection initiatives are taking on wide roles in everyday human interaction (such as educational cheating and employee credibility assessment), the integration of the approaches into children’s activities may serve to normalise the processes involved. Older children who already have some sense of what lying constitutes may find in the lie detection toys and games some insights as to how to become more effective as liars. Some parents may use these lie-detection toys in misguided attempts to determine whether their children are lying to them about something. Many toys and games are explicit in their lie detection and surveillance themes, with specific narratives relating to the societal roles of detectives and spies. Children become complicit in the societal functions of lie detection, rather than simply being subjects or audiences to them. Children’s toys and games are all about experimentation, and these lie detection artifacts are no different (Oravec 2000). Children are enabled through interactions with the toys and games to experiment with lying behavior and possibly explore certain aspects of their own mental lives as well as those of others. Children can learn how to modulate some of the external physiological signals that are often associated with lying, much in the way that individuals can alter various physiological responses with assistance of biofeedback technologies. Such efforts may be empowering in some senses but also increase the potential for confusion about truthfulness and lying. Use of the toys and games may support the emergence of psychopathic tendencies in which children exhibit antisocial and egocentric behavior along with a failure to learn about the consequences of their actions, in this case lying (Hermann). This situation is comparable to that of organisations that advertise training for how to “beat” or “outsmart” polygraphs, efforts that have often confounded law enforcement and intelligence agencies (Rosky). Playing with the Truth: Children and Honesty The constructions of lie detection events that are fostered in these toys and games generally simplify and mechanise truth-lie differences, and often present them in an unquestioning manner. Children are not encouraged to wonder whether the devices are indeed functioning as stated in the instructions and advertising materials. Failure to inform children about the toys’ intents and to request their consent about lie detection could also challenge some of them to attempt to subvert the toys’ mechanisms. However, many lie detection toys and games provide the opportunity for historically grounded lessons for children about the detection and surveillance strategies of other eras, if introduced in a critical and context-sensitive manner. The assumption that effective lie detection is possible and mental privacy is thus limited is reinforced by the framings of many of these toys and games (Oravec “Emergence”). Lying is indeed a reflection of “Theory of Mind” which enables us to imagine the minds of others, and children are given an arena for exploration on this theme. However, children also learn that their mental worlds and streams of consciousness are readily accessible by others with the use of certain technologies. Scientific justification for the use of polygraphs through the past decades has yielded problematic results, although polygraphs and many other lie detection technologies have still retained social acceptability apparently related to their cultural appeal (Paul, Fischer, and Voigt). Many voice stress apps are also not reliable according to recent research (Tyrsina). The normalisation of current and projected systems for lie detection and mental privacy incursions presents unsettling prospects for children’s development, and the designers and disseminators of toys and games need to consider these dimensions. Using technologically enhanced games, toys, or robots to detect “lies” rather than engaging more directly with other humans in a game context may have unfortunate overall outcomes. For example, the ability to practice various schemes to evade detection while lying may be an attractive aspect of these toys and games to some individuals. The kinds of input often linked with lying behaviors (or “leakage”) can include physiological changes in voice qualities that are generally not directly controllable by the speaker without specific practice; the games and toys provide such practice venues. Individuals who are able to disconnect from their autonomic expressions and lie without physical or acoustic signs can exacerbate personality issues and social pathologies. Some may become psychopaths, who lie to get their way and tend not to feel remorseful, with the games and toys potentially exacerbating genetic tendencies; others may become pathological liars, who lie regardless of whether there is specific benefit to them in doing so (Vrij). Some of these toy-related spying and detective activities can unfortunately be at the expense of others’ wellbeing, whatever their impacts on the children directly involved as players. For example, some forms of lie detection technologies incorporate the remote collection of data without notification of participants, as in the voice-analysis systems just described. Children’s curiosity about others’ thoughts and mental lives may be at the root of such initiatives, though children can also utilise them for bullying and other forms of aggressive behavior. Some research shows that early lie telling by children is often linked with self-defense as they attempt to save face, but other research couples it with anti-social action and behavioral problems (Lavoie). However, adults have been shown to have some considerable influence on children in their lie-telling conduct (Dykstra, Willoughby, and Evans), so there is hope that parents, guardians, teachers, and concerned community members can have some positive influence. Reflections and Conclusions: The “New Pinocchio”? Toys and games can indeed project comforting and nurturing imageries for children. However, they can also challenge individuals to think differently about themselves and others, and even present dystopian scenarios. For toy and game developers to promote lie detection technologies can be problematic because of the associations of lying with antisocial activity and behavioral problems as well as moral concerns. The characters that children play in roles of spies and lie detector administrators supply them with powerful narratives and impact on their mental concepts. The significance of truth-telling in children’s lives is expanding as societal attention to credibility issues increases. For example, children are often called on to present evidence during divorce proceedings and abuse-related cases, so there is a significant body of research about children’s verbal truth and deception patterns (Talwar, Lavoie, and Crossman). The data collected by some networked lie detection toys (such as voice stress analysers) can subsequently be used by third-parties for marketing purposes or direct surveillance, raising critical questions about consent (Oravec “Emergence”). Future entertainment modes may soon be developed with lie detection approaches comparable to the ones I discuss in this article, since many games rely on some form of mental privacy assumptions. Games often have some aspect of personal cognitive control at their roots, with the assumption that individuals can shield their own deliberations from other players at least to some extent. Technological capabilities for lie detection can alter the kinds of strategies involved in games. For example, if players know the quality of other players’ poker hands through technological means, games would need to be restructured substantially, with speed of response or other aspects at a premium. The current and future toy and game developments just discussed underscore the continuing need for ethical and professional vigilance on the part of researchers and developers as they choose projects to work on and technologies to bring to market. Children and young people who play with lie detection and surveillance-related artifacts are being exposed to assumptions about how their own consciousness functions and how they can best navigate in the world through truth-telling or lying. Although children once acquired insights about lying though moral fables like Pinocchio, they are now learning from corporate-developed technological toys and games. References Alder, Ken. The Lie Detectors: The History of an American Obsession. Simon and Schuster, 2007. Bergers, Lara. “Only in America? A History of Lie Detection in the Netherlands in Comparative Perspective, ca. 1910–1980.” The Netherlands: Utrecht U, 2018. <https://studenttheses.uu.nl/handle/20.500.12932/30502>. Bunn, Geoffrey C. The Truth Machine: A Social History of the Lie Detector. Johns Hopkins UP, 2012. Dykstra, Victoria, Teena Willoughby, and Angela D. Evans. "Perceptions of Dishonesty: Understanding Parents’ Reports of and Influence on Children and Adolescents’ Lie-Telling." Journal of Youth and Adolescence 49 (2020): 49–59. <https://doi.org/10.1007/s10964-019-01153-5>. Ekman, Paul. Telling Lies. New York: Norton, 1985. Granich, Mike. “17 Spy Gadgets and Spy Gear for Kids to Gift This Year.” Technolocheese, 2020. 14 Feb. 2020 <https://www.technolocheese.com/spy-gear-for-kids/>. Hermann, Henry. Dominance and Aggression in Humans and Other Animals: The Great Game of Life. Elsevier, 2017. Lavoie, Jennifer, et al. "Lie-telling as a Mode of Antisocial Action: Children’s Lies and Behavior Problems." Journal of Moral Education 47.4 (2018): 432–450. <https://doi.org/10.1080/03057240.2017.1405343>. Littlefield, Melissa. The Lying Brain: Lie Detection in Science and Science Fiction. U of Michigan P, 2011. McQuarrie, Laura. “Hasbro's Lie Detector Game Uses Voice Analysis to Pick Up on Untruths.” Trendhunter, 2019. <https://www.trendhunter.com/trends/lie-detector-game>. Oravec, Jo Ann. "Interactive Toys and Children's Education: Strategies for Educators and Parents." Childhood Education 77.2 (2000): 81-85. ———. "The Emergence of 'Truth Machines'? Artificial Intelligence Approaches to Lie Detection." Ethics and Information Technology 24.6 (2022). <https://link.springer.com/article/10.1007/s10676-022-09621-6>. Paul, Bettina, Larissa Fischer, and Torsten Voigt. “Anachronistic Progress? User Notions of Lie Detection in the Juridical Field.” Engaging Science, Technology, and Society 6 (2020): 328–346. <https://doi.org/10.17351/ests2020.433>. Pearson, Yvette. "Child-Robot Interaction: What Concerns about Privacy and Well-Being Arise When Children Play with, Use, and Learn from Robots?" American Scientist 108.1 (2020): 16–22. 22 June 2023 <https://link.gale.com/apps/doc/A613271878/AONE?u=anon~66b204b9&sid=googleScholar&xid=067570c2>. Perella, Nicolas. "An Essay on Pinocchio." Italica 63.1 (1986): 1–47. <https://doi.org/10.2307/479125>. Price, Emily. “Hasbro Is Launching a Lie Detector Party Game and Ghost-Busting Robot.” Fortune, 2019. 15 Feb. 2019 <http://fortune.com/2019/02/15/lie-detector-party-game/>. “Project MC2.” Amazon, 2020. <https://www.amazon.com/Project-Mc2-539230-Lie-Detector/dp/B015A7CHSA>. Rosky, Jeffrey. "The (F)utility of Post-Conviction Polygraph Testing." Sexual Abuse 25.3 (2013): 259–281. <https://doi.org/10.1177/1079063212455668>. Science Buddies. “Pinocchio’s Arm: A Lie Detector Test.” Scientific American, 10 Mar. 2016. <https://www.scientificamerican.com/article/pinocchio-s-arm-a-lie-detector-test/>. “Shocking Liar.” Amazon, 2020. <https://www.amazon.com/Dayan-Cube-Lie-Detector-Game/dp/B000GUGTYU>. Talwar, Victoria, Jennifer Lavoie, and Angela Crossman. "Carving Pinocchio: Longitudinal Examination of Children’s Lying for Different Goals." Journal of Experimental Child Psychology 181 (2019): 34–55. <https://doi.org/10.1016/j.jecp.2018.12.003>. “TIME’s New Products.” TIME Magazine 78.1 (7 July 1961): 35. Tyrsina, Radu. “These 2 Lie Detecting Programs for PC Will Help You Determine the Truth from All the Lies.” Windowsreport, 5 Aug. 2017. <https://windowsreport.com/lie-detector-software-pc/>. Vrij, Aldert. Detecting Lies and Deceit: Pitfalls and Opportunities. John Wiley & Sons, 2008. Zhu, Dingju. "Feedback Big Data-Based Lie Robot." International Journal of Pattern Recognition and Artificial Intelligence 32.2 (2018). <https://doi.org/10.1142/S0218001418590024>.

Years have come and gone and Bob is still around He’s tied up by his ankles and he’s hanging upside downA lifetime of infection and his lungs all filled with phlegmThe CF would’ve killed him if it weren’t for S&M Supermasochistic Bob has Cystic Fibrosis by Bob Flanagan. Soundtrack from 1997 documentary, Sick: The Life & Death of Bob Flanagan In the 1997 film, Sick: The Life & Death of Bob Flanagan, Supermasochist, artist Bob Flanagan quite literally lays himself bare to the viewer. This is a wrenching documentary which charts the dying Flanagan’s battles with cystic fibrosis (CF), and also explores the impact of this on his art and life. Sick also explores to an explicit degree the sadomasochist practices that permeated Flanagan’s private life and performance art practice, and which he used as a means of asserting control of the chronic pain and infirmity of his medical condition. Sick is not an easy watch. The film evokes feelings of fear, empathy, and horror. It challenges notions of taste and bad taste. It subjects the viewer to witness the vulnerability of the repeatedly tortured and invaded body of the artist, and of his eventual confrontation with death. As performance pieces go, this is an extreme example of body-based art. Where does this extraordinary piece stem from? From which traditions in art does it draw? To answer these questions, it is necessary to examine the framework of disability art, transgressive art, and also the tradition of medical Gothic, or the history of the Gothic body as a site of art—art that involves reading the body as carnivalesque, as degenerate, as ab-human, as abject entity. The Gothic Body as Site of Art The body has long been a site of exploration in medical practice and in artistic practice. The body has been displayed and examined in various forms, as subject, object, or abject entity through ossories, medical collections, museums of pathology, and freak shows. Paintings of crucifixions and martyrdoms, and practices of flagellation have glorified the tortured body of Christians as physical reminders of extreme piety. The abnormal or monstrous body has been a trope in art since the medieval period, often identified with ideas of evil or sin. Anatomical bodies have been referenced and explored by artists since the Renaissance. With the popular explosion of performance art in the 1960’s, bodily practices have been incorporated into site specific art. Artists’ bodies are offered for our gaze, and sometimes for interaction with, all within the context of performance. Although performance art originates in the early 20th century, it was exponents of the 1960’s that firmly aligned this practice with the site of the artist’s body. At this time, the body became a new focus of culture, with the rise in sexual freedom and the accepted use of nudity in performances and happenings. This resulted in the performance of body-based pieces such as Carolee Schneemann’s Meat Joy (1964) and Interior Scroll (1975), Hermann Nitsch and the Viennese Actionists and their Theatre of Orgies and Mysteries (1962), and Vito Acconci’s Seedbed (1971). This legacy of sexual, violent, or abject performances results in the creation of provocative and disturbing contemporary pieces such as Sick that confront the spectator with the vulnerabilities and limits of the living body. Today, contemporary culture is suffused with images of the body, both the idealised bodies of advertising and music videos, and the grotesque and transfigured bodies of contemporary art. Spooner has commented, “Contemporary Gothic is more obsessed with bodies than in any of its previous phases: bodies become spectacle, provoking disgust, modified, reconstructed and artificially augmented” (63). Today, culture’s preoccupation with the body runs the gamut from horror films obsessed with the penetrated body, to subcultural style and body manipulation, and the increasing popularity of plastic surgery makeovers on mainstream television. The body has never been so exposed, so open to the audience’s gaze. Key artists such as Damien Hirst, Mat Collishaw, the Chapman Brothers, Gabriela Friðriksdóttir, and Sue de Beer respond to this contemporary preoccupation by exploring the body in its manifold Gothic forms. This is a rich body of work that uses abject materials, references slasher movies, and plays with notions of identity, societal violence, body-horror, and the grotesque. This article looks specifically at works by contemporary transgressive artists that utilise their own bodies as site of performance, and the challenges to accepted tastes that this work poses. Performances by Bob Flanagan, Ron Athey, and Marina Abramovic are analysed in terms of boundaries, identity, and other implications in using the body of the artist as the site of art. Tropes of torture, pain. and body modification are examined as contesting the parameters of what body limits and of what is acceptable in contemporary art practice. An Intimate Canvas: The Artist’s Body as Site So what does it mean to use your own body as site of exploration? The work of artists who use their own bodies as a site of spectacle, as a medium of art, has several interesting implications. By its very nature, such an act is transgressive. It blurs the boundaries between artwork and artist. This creates an interesting tension between self and other and, indeed, arguably explores the notion of self as other. This work has an autobiographical function, in that it not only reveals universal themes of significance to the artist but, given the intimacy of the canvas, it also betrays personal preoccupations, and signifies the artist’s own relationship with the body and bodily practices. The use of the human body as canvas brings an intense physical and emotional proximity to the piece. The bodily traumas that are witnessed via performance art—whether it is Chris Burden being nailed to a Volkswagen (Trans-fixed, 1974) or Marina Abramović and Ulay collapsing, unconscious, lungs filled with carbon dioxide from reciprocal exchange of breaths (Breathing In/Breathing Out, 1977)—constitute an intimate link with the audience that arises from the shock of witnessing these transgressive acts. The body of the artist exposed in this way—a body normally only viewed by a partner, doctor or close family member—creates immediacy, giving the individual spectator in an intimate connection with the artist. Francesca Gavin, in her introductory essay to Hellbound: New Gothic Art, cites this voyeurism as essential to the experience of viewing Gothic art: “By looking at the violence or horror we become complicit in its creation, part of the cause—hence part of the discomfort in looking” (7). The first of these areas of discomfort to consider is the association of the body with pain, torture and mutilation, and the use of the artist’s body to explore this theme. Pushing the Limits: The Artist’s Body as Site of Pain The work of Marina Abramović has had a powerful effect on the contemporary landscape of body-based performance art that tests the limits of endurance of the corporeal body. Her past projects have focused on the uneasy power exchange between audience and performer. In Rhythm 0 (1974), her first long durational performance, Abramović offered her audience a choice of 72 objects including a gun, a hammer, sugar, and scissors, to be used on her own body, without any limitations on their deployment. This six-hour performance featured a motionless Abramović offering her body passively to the spectators to interact with. The intensity of the resulting video piece is remarkable; the recording of the performance captures the potential dissolution of the societal contract between artist and audience, a mutable discourse of agency and power. Abramović spoke of the sense of fear she experienced during this performance— “I felt really violated: they cut up my clothes, stuck rose thorns in my stomach, one person aimed the gun at my head, and another took it away. It created an aggressive atmosphere” (quoted, Danieri 30). Her work plays constantly with the idea of boundaries and limits, often pushing her physical self past extraordinary barriers of pain and exertion, as in Rhythm 5 (1974) where she lost consciousness as a result of smoke inhalation and had to be rescued by the spectators. Amelia Jones has analysed these performances of pain as central to the artist’s desire to establish a connection with the audience during performances: “While pain cannot be shared, its effects can be projected onto others such that they become the site of suffering […] and the original sufferer can attain some semblance of self-containment (paradoxically, through the very penetration and violation of the body” (230). One could also argue that this sharing of experience also effectively normalises the abnormal body by establishing a common bond between viewer and performer. However, this work raises questions for the viewer. Is what these artists do self-harm, presented on a public stage? Is this ethical? And, importantly, is it within the bounds of taste? The answer, it would seem, lies in issues of agency and control and, of course, in the separation of art from life that occurs due to the act of performing itself. As Coogan puts it “[t]he performance frame is contingent and temporary, holding the performer in a liminal, provisional and suspended place” (1). While Abramović’s work experiments with bodily endurance and performative limits, other artists who produce autobiographical, body-based performance can be located within the world of medical discourse and performed disability. An artist who subverts the boundaries of the body, and taste alike, is Ron Athey, the HIV-positive artist who makes performance work based on blood rituals, torture, and cutting. His use of blood is central to his practice, and the fact that this blood, which is let through performances, contains the HIV virus, gives it a doubly abject aspect. His performance Excerpted Rites Transformation (1995) which took place at the Walker Art Museum in Minneapolis caused an extreme reaction. During this performance Athey pierced own his skin with needles, and also cut into the skin of black artist Daryl Carlton in a mimicry of tribal scarification rituals that highlighted issues of race, then hung handkerchiefs dipped in Carlton’s blood on clotheslines that ran over the heads of the audience. Mary Abbe, an art critic with the Minneapolis Star Tribune who had not attended the performance, wrote an article about the danger posed to the audience by what she wrongly termed Athey’s blood. (Carlton is not HIV positive). It is clear from the tone of this response that such disease causes a profound dis-ease in the beholder. Bob Flanagan’s oeuvre also locates him in this tradition of artists who perform their disability on a public stage. Critics such as Kuppers consider Athey and Flanagan as artists who subvert the medical gaze (Foucault), refusing to accept the passive role of ‘patient’, and defiantly flaunting their abnormal bodies in the public arena. These bodies can also be considered as modified bodies. Sandahl has contextualised Athey’s performance as going beyond the parameters of the human body: “Athey’s radical cyborg identity is a temporary mode of survival, an alternative way of being in there here and now. A body not interested solely in cure nor submissive to medical interventions” (59). Kuppers, in The Scar of Visibility: Medical Performances and Contemporary Art, reflects on Flanagan and Athey’s careers as disabled artists. She examines how Flanagan constructs his identity as a chronically ill artist, and his pain performances that allowed him to avoid attracting the sentimental pity associated with illness; replacing audience empathy with shock and often revulsion. Kuppers highlights Flanagan’s use of dark humour in his performances through songs like Fun to be Dead (1997), which work to subvert the dominance of his illness. In fact, Flanagan’s work often asserts his central belief that his relative longevity (he lived to be 43, a decade longer than most CF sufferers) was achieved by his ability to counter the pain of his chronic condition with the pain of his masochistic suffering. The stereotype that the masochist is snivelling and weak is actually not true. The masochist has to know his or her own body perfectly well and be in full control of their body, in order to give control to somebody else or to give control to pain. So the masochist is actually a very strong person. I think some of that strength is what I use to combat the illness. (Dick) Athey’s description of his relief at the act of cutting echoes Flanagan’s identification of these rites as way of asserting control over a dysfunctional body: “The sight of your own blood, brought forth from your own hand, spells an almost immediate relief, a release to the pressure valve. It’s a violation that you yourself now control.” What effect does this painful and masochistic art have on the audience? On the act of viewing? On taste itself? Taste and Transgression: Beyond the Parameters of the Body The notion of taste is a hotly debated area in contemporary art practice—arguments rage as to what constitutes good or bad taste. Woodward argues that “[B]ad taste often passes for avant-garde taste these days—so long as the artist signals ‘transgressive’ intent” (1). Grunenberg (1997) has addressed the problematic notion of the audience engagement with this mode of Gothic art, asking whether it has ilost its power to shock. He contends that with the contemporary saturation of all media with violent and shocking imagery, “the ability to be shocked and moved by real or fictitious images of horror has been showing positive signs of attrition.” Nevertheless, the proximity of performance, the immediacy of the artist’s body as canvas, the feelings of horror, empathy, and even wonder occasioned by the manipulation and excesses of the body, continue to draw audiences. The artist’s body as site of performance becomes a space in which the audience may inscribe their own narratives. The body is a locus of projection, almost ab-human, “a not-quite-human subject, characterised by its morphic variability, continually in danger of becoming not-itself, becoming other” (Hurley 3–4). As the artist’s body becomes ever more manipulated and pushed beyond boundaries of taste and pain, it forces artist and audience alike to ask what lies beyond the parameters of the body. Experimentation with torture methods, with cutting, with abject materials, seems to lead back inevitably to the notion of Gothic, othered body, and a desire to pass beyond the boundaries of the repeatedly invaded and wracked body. Once you transgress the boundaries of the body, the logical locus that lies beyond is death. Dick’s Sick documents Bob Flanagan’s death, which formed part of the agreement between documentary maker and artist before shooting. Flanagan hoped his body art would continue beyond death: “I want a wealthy collector to finance an installation in which a video camera will be placed in the coffin with my body, connected to a screen on the wall, and whenever he wants to, the patron can see how I’m coming along” (Dick). Playing with the shadow of death becomes a mode of performance itself. Abramović recalls her acceptance of this fact in her early performance pieces: “When I was in Yugoslavia I was always thinking that art was a kind of question between life and death and some of my performances really included the possibility of dying, you know, during the piece, it could happen” (quoted in McEvilley 15). She also records her fear experienced during Rhythm 0 (1974), stating “What I learned was that [... ]if you leave it up to the audience, they can kill you” (quoted in Danieri 29). Death has receded from us in the 21st century. Death happens in hospitals, in the antiseptic confines of the Intensive Care Unit, it is medicated and mediated by medical staff. Traditional rituals of deathbed conversations and posthumous wakes are gradually disappearing. The discourse of death has grown silent except through the medium of the Gothic and especially the Gothic body, as the Gothic “consistently attempts to speak about the unspeakable—that is, death” (McGrath 154). Artists such as Abramović, Flanagan, and Athey function within this Gothic tradition. By insistently presenting their Gothic bodies, they force the audience to acknowledge death, transgression, and decay as realities. With collaborative partners, they mediate the process of surgery, torture, dying, and even the moment of death through photography and lens-based media. This use of media in capturing the moment also functions in a contemporary post-religious society as a mode of replication and, even, perhaps, of immortality. Bold, provocative, and challenging, the work of these transgressive artists continues to challenge the idea of bodily limits and boundaries and highlight the notion of the body as site of transformation. They continue to challenge our taste, our definition of art, and our comfort as audience. The words of Gavin come again to mind: “By looking at the violence or horror we become complicit in its creation, part of the cause—hence part of the discomfort in looking” (7). Using the artist’s body as site of performance forces us to challenge our conception of art, illness, life and death and leads to a reappraisal of taste itself. References Abbe, Mary. “Bloody Performance Draws Criticism.” Star Tribune 24 Mar. 1994. 1A. Abramovic, Marina. [website] 4 Feb. 2014. ‹http://www.marinaabramovicinstitute.org›. Athey, Ron. [website] 4 Feb. 2014. ‹http://ronatheynews.blogspot.ie›. Coogan, Amanda. “What is Performance Art?.” Irish Museum of Modern Art [website] (2011). 4 Feb. 2014 ‹http://www.imma.ie/en/page_212496.htm›. Daneri, Anna, Giacinto Di Pietrantonio, L. Hegyi, SR Sanzio, & A. Vettese. Eds. Marina Abramović. Milan: Charta, 2002. Dick, Kirby. Sick: The Life & Death of Bob Flanagan, Supermasochist. Dir. Kirby Dick. 1997. Flanagan, Bob. [website] 4 Feb. 2014. ‹http://vv.arts.ucla.edu/terminals/flanagan/flanagan.html›. Gavin, Francesca. Hellbound: New Gothic Art. London: Laurence King Publishing, 2008. Grunenberg, Christoph. “Unsolved Mysteries: Gothic Tales from Frankenstein to the Hair Eating Doll.” Gothic: Transmutations of Horror in Late Twentieth Century Art. Ed. Christoph Grunenberg. Boston: MIT Press, 1997. Hurley, Kelly. The Gothic Body: Sexuality, Materialism, and Degeneration at the Fin de Siècle. Cambridge: Cambridge UP, 1997. 160–212. Kuppers, Petra. The Scar of Visibility: Medical Performances and Contemporary Art. Minneapolis: U of Minnesota P, 2007. Mc Grath, Patrick. “Transgression and Decay.” Gothic: Transmutations of Horror in Late Twentieth Century Art. Ed. Christoph Grunenberg. Boston: MIT Press, 1997. 153–58. Spooner, Catherine. Contemporary Gothic. London: Reaktion Books, 2006. Sandahl, Carrie. “Performing Metaphors: Aids, Disability and Technology.” Contemporary Theatre Review 11.3–4 (2001): 49–60. Woodward, Richard B. “When Bad is Good.” ARTnews [website] (2012). 4 Feb. 2014. ‹http://www.artnews.com/2012/04/12/when-bad-is-good›. Zylinska, Joanna. The Cyborg Experiments: The Extensions of the Body in the Media Age. London: Continuum, 2002.

IntroductionThis essay will focus on some of the connections between digitally transmitted stories, games, narrative processes, and the discipline whose ostensible job is the study of storytelling, namely literature. My observations will be limited to the specific case of computer games, storytelling, and what is often unproblematically referred to as “literature,” in order to focus attention on historical and contemporary features of the development of the relationship between the two that remain largely unexamined. Therefore, one goal of this essay is to re-think this relationship from a fresh perspective, whose “freshness” derives from reopening the past and re-examining what is overlooked when games scholars talk about “narrative” and “literature” as though they were interchangeable.Further, I will discuss the dissemination of narrative on/through various platforms before mass-media, such as textually transmitted stories that anticipate digitally disseminated narrative. This will include specific examples as well as a more general a re-examination of claims made on the topic of literature, narrative and computer games, via a brief review of disciplinary insights from the study of digital games and narrative. The following is therefore intended as a view of games and (literary) narrative in pre-digital forms as an attempt to build bridges between media studies and other disciplines by calling for a longer, developmental history of games, narrative and/or literature that considers them together rather than as separate territories.The Stakes of the Game My reasons for re-examining games and narrative scholarship include my desire to discuss a number of somewhat less-than-accurate or misleading notions about narrative and literature that have been folded into computer game studies, where these notions go unchallenged. I also want to point out a body of work on literature, mimesis and play that has been overlooked in game studies, and that would be helpful in thinking about stories and some of the (digital) platforms through which they are disseminated.To begin by responding to the tacit question of why it is worth asking what literary studies have to do with videogames, my answer resides in the link between play, games and storytelling forged by Aristotle in the Poetics. As a function of imitative play or “mimesis,” he claims, art forms mimic phenomena found in nature such as the singing of birds. So, by virtue of the playful mimetic function ascribed to the arts or “poesis,” games and storytelling are kindred forms of play. Moreover, the pretend function common to art forms such as realist fictional narratives that are read “as if” the story were true, and games played “as if” their premises were real, unfold in playfully imitative ways that produce possible worlds presented through different media.In the intervening centuries, numerous scholars discussed mimesis and play from Kant and Schiller in the 18th century, to Huizinga, and to many scholars who wrote on literature, mimesis and play later in the 20th century, such as Gadamer, Bell, Spariousu, Hutchinson, and Morrow. More recently, games scholar Janet Murray wrote that computer games are “a kind of abstract storytelling that resembles the world of common experience but compresses it in order to heighten interest,” hence even Tetris acts as a dramatic “enactment of the overtasked lives of Americans in the 1990’s” allowing them to “symbolically experience agency,” and “enact control over things outside our power” (142, 143). Similarly, Ryan has argued that videogames offer micro stories that are mostly about the pleasure of discovering nooks and crannies of on-line, digital possible worlds (10).At the same time, a tendency developed in games studies in the 1990s to eschew any connection with narrative, literature and earlier scholarship on mimesis. One example is Markku Eskelinen’s article in Game Studies wherein he argued that “[o]utside academic theory people are usually excellent at making distinctions between narrative, drama and games. If I throw a ball at you I don’t expect you to drop it and wait until it starts telling stories.” Eskelinen then explains that “when games and especially computer games are studied and theorized they are almost without exception colonized from the fields of literary, theatre, drama and film studies.” As Eskelinen’s argument attests, his concern is disciplinary territorialisation rather than stories and their transmedial dissemination, whereas I prefer to take an historical approach to games and storytelling, to which I now direct my attention.Stepping Back Both mimesis and interactivity are central to how stories are told and travel across media. In light thereof, I recall the story of Zeuxis who, in the 5th century BC, introduced a realistic method of painting. As the story goes, Zeuxis painted a boy holding a bunch of grapes so realistically that it attracted birds who tried to enter the world of the painting, whereupon the artist remarked that, were the boy rendered as realistically as the grapes, he would have scared the birds away. Centuries later in the 1550s, the camera obscura and mirrors were used to project scenery as actors moved in and out of it as an early form of multimedia storytelling entertainment (Smith 22). In the late 17th century, van Mieris painted The Raree Show, representing an interactive travelling storyboard and story master who invited audience participation, hence the girl pictured here, leaning forward to interact with the story.Figure 1: The Raree Show (van Mieris)Numerous interactive narrative toys were produced in the 18th and 19th, such as these storytelling playing cards sold as a leaf in The Great Mirror of Folly (1720). Along with the plays, poems and cartoons also contained in this volume dedicated to the South Sea Bubble crisis of 1720, the cards serve as a storyboard with plot lines that follow suits, so that hearts picks up one narrative thread, and clubs, spades and diamonds another. Hence while the cards could be removed for gaming they could also be read as a story in a medium that, to borrow games scholar Espen Aarseth’s terminology, requires non-trivial physical or “ergodic effort” on the part of readers and players.Figure 2: playing cards from The Great Mirror of Folly (1720) In the 20th century examples of interactive and ergodic codex fiction abound, including Hesse’s Das Glasperlenspiel [Glass Bead Game] (1943, 1949), Nabokov’s Pale Fire (1962), Saporta’s Composition No. 1 (1962), and Winterson’s PowerBook (2001) that conceptually and/or physically mimic and anticipate hypertext. More recently, Chloé Delaume’s Corpus Simsi (2003) explicitly attempts to remediate a MMORPG as the title suggests, just as there are videogames that attempt, in various ways, to remediate novels. I have presented these examples to argue for a long-continuum view of storytelling and games, as a series of attempts to produce stories—from Zeuxis grapes to PowerBook and beyond—that can be entered and interacted with, at least metaphorically or cognitively. Over time, various game-like or playful interfaces from text to computer have invited us into storyworlds while partially impeding or opening the door to interaction and texturing our experience of the story in medium-specific ways.The desire to make stories interactive has developed across media, from image to text and various combinations thereof, as a means of externalizing an author’s imagination to be activated by opening and reading a novel, or by playing a game wherein the story is mediated through a screen while players interact to change the course of the story. While I am arguing that storytelling has for centuries striven to interpolate spectators or readers by various means and though numerous media that would eventually make storytelling thoroughly and not only metaphorically interactive, I want now to return briefly to the question of literature.Narrative vs LiteratureThe term “literature” is frequently assumed to be unambiguous when it enters discussions of transmedia storytelling and videogames. What literature “is” was, however, hotly debated in the 1980s-90s with many scholars concluding that literature is a construct invented by “old dead white men,” resulting in much criticism on the topic of canon formation. Yet, without rehearsing the arguments produced in previous decades on the topic of literariness, I want to provide a few examples of what happens when games scholars and practitioners assume they know what literature is and then absorb or eschew it in their own transmedia storytelling endeavours.The 1990s saw the emergence of game studies as a young discipline, eager to burst out of the crucible of English Departments that were, as Eskelinen pointed out, the earliest testing grounds for the legitimized study of games. Thus ensued the “ludology vs narratology” debate wherein “ludologists,” keen to move away from literary studies, insisted that games be studied as games only, and participated in what Gonzalo Frasca famously called the “debate that never happened.” Yet as short-lived as the debate may have been, a negative and limited view of literature still inheres in games studies along with an abiding lack of awareness of the shared origins of stories, games, and thinking about both that I have attempted to sketch out thus far.Exemplary of arguments on the side of “ludology,” was storytelling game designer Chris Crawford’s keynote at Mediaterra 2007, in which he explained that literariness is measured by degrees of fun. Hence, whereas literature is highly formulaic and structured, storytelling is unconstrained and fun because storytellers have no rigid blueprint and can change direction at any moment. Yet, Crawford went on to explain how his storytelling machine works by drawing together individual syntactic elements, oddly echoing the Russian formalists’ description of literature, and particularly models that locate literary production at the intersection of the axis of selection, containing linguistic elements such as verbs, nouns, adjectives and so on, and the axis of combination governed by rules of genre.I foreground Crawford’s ludological argument because it highlights some of the issues that arise when one doesn’t care to know much about the study of literature. Crawford understands literature as rule-based, rigid and non-fun, and then trots out his own storytelling-model based or rigid syntactical building blocks and rule-based laws of combination, without the understanding the irony. This returns me to ludologist Eskelinen who also argued that “stories are just uninteresting ornaments or gift-wrappings to games”. In either case, the matter of “story” is stretched over the rigid syntax of language, and the literary structuralist enterprise has consisted precisely in peeling back that narrative skin or “gift wrap” to reveal the bones of human cognitive thought processes, as for example, when we read rhetorical figures such as metaphor and metonymy. In the words of William Carlos Williams, poetry is a machine made out of words, from whose nuts and bolts meaning emerges when activated, similar to programing language in a videogame whose story is eminent and comes into being as we play.Finally, the question of genre hangs in the background given that “literature” itself is potentially transmedia because its content can take many forms and be transmitted across diverse platforms. Importantly in this regard the novel, which is the form most games scholars have in mind when drawing or rejecting connections between games and literature, is itself a shape-shifting, difficult-to-define genre whose form, as the term novel implies, is subject to the constant imperative to innovate across media as it has done over time.Different Approaches While I just highlighted inadequacies in some of the scholarship on games and narrative (or “literature” when narrative is defined as such) there is work on interactive storytelling and the transmedia dissemination of stories explicitly as games that deals with some of these issues. In their article on virtual bodies in Dante’s Inferno (2010), Welsh and Sebastian explain that the game is a “reboot of a Trecento poem,” and discuss what must have been Dante’s own struggle in the 14th century to “materialize sin through metaphors of suffering,” while contending “with the abstractness of the subject matter [as well as] the representational shortcomings of language itself,” concluding that Dante’s “corporeal allegories must become interactive objects constructed of light and math that feel to the user like they have heft and volume” (166). This notion of “corporeal allegories” accords with my own model of a “body hermeneutic” that could help to understand the reception of stories transmitted in non-codex media: a poetics of reading that includes how game narratives “engage the body hapitically” (Goggin 219).Likewise, Kathi Berens’s work on “Novel Games: Playable Books on iPad” is exemplary of what literary theory and game texts can do for each other, that is, through the ways in which games can remediate, imitate or simply embody the kind of meditative depth that we encounter in the expansive literary narratives of the 19th century. In her reading of Living Will, Berens argues that the best way to gauge meaning is not in the potentialities of its text, but rather “in the human performance of reading and gaming in new thresholds of egodicity,” and offers a close reading that uncovers the story hidden in the JavaScript code, and which potentially changes the meaning of the game. Here again, the argument runs parallel to my own call for readings that take into account the visceral experience of games, and which demands a configurative/interpretative approach to the unfolding of narrative and its impact on our being as a whole. Such an approach would destabilize the old mind/body split and account for various modes of sensation as part of the story itself. This is where literary theory, storytelling, and games may be seen as coming together in novels like Delaume’s Corpus Simsi and a host of others that in some way remediate video games. Such analyses would include features of the platform/text—shape, topography, ergodicity—and how the story is disseminated through the printed text, the authors’ websites, blogs and so on.It is likewise important to examine what literary criticism that has dealt with games and storytelling in the past can do for games. For example, if one agrees with Wittgenstein that language is inherently game-like or ludic and that, by virtue of literature’s long association with mimesis, its “as if” function, and its “autotelic” or supposedly non-expository nature, then most fiction is itself a form of game. Andrew Ferguson’s work on Finnegan’s Wake (1939) takes these considerations into account while moving games and literary studies into the digital age. Ferguson argues that Finnegan’s Wake prefigures much of what computers make possible such as glitching, which “foregrounds the gaps in the code that produces the video-game environment.” This he argues, is an operation that Joyce performed textually, thereby “radically destabilizing” his own work, “leading to effects [similar to] short-circuiting plot events, and entering spaces where a game’s normal ontological conditions are suspended.” As Ferguson points out, moreover, literary criticism resembles glitch hunting as scholars look for keys to unlock the puzzles that constitute the text through which readers must level up.Conclusion My intention has been to highlight arguments presented by ludologists like Eskelinnen who want to keep game studies separate from narrative and literary studies, as well as those game scholars who favour a narrative approach like Murray and Ryan, in order to suggest ways in which a longer, historical view of how stories travel across platforms might offer a more holistic view of where we are at today. Moreover, as my final examples of games scholarship suggest, games, and games that specifically remediate works of literature such as Dante’s Inferno, constitute a rapidly moving target that demands that we keep up by finding new ways to take narrative and ergodic complexity into account.The point of this essay was not, therefore, to adapt a position in any one camp but rather to nod to the major contributors in a debate which was largely about institutional turf, and perhaps never really happened, yet still continues to inform scholarship. At the same time, I wanted to argue for the value of discussing the long tradition of understanding literature as a form of mimesis and therefore as a particular kind of game, and to show how such an understanding contributes to historically situating and analysing videogames. Stories can be experienced across multiple platforms or formats, and my ultimate goal is to see what literary studies can do for game studies by trying to show that the two share more of the same goals, elements, and characteristics than is commonly supposed.ReferencesAristotle. Poetics, Trans. J. Hutton. New York: W.W. Norton & Company, 1982.Aarseth, Espen. Cybertext: Perspectives on Ergodic Literature. Baltimore: Johns Hopkins UP, 2007.Behrens, Kathi. “‘Messy’ Ludology: New Dimensions of Narrator Unreliability in Living Will.” No Trivial Effort: Essays on Games and Literary Theory. Eds. Joyce Goggin and Timothy Welsh. Bloomsbury: Forthcoming.Bell, D. Circumstances: Chance in the Literary Text. Lincoln: Nebraska UP, 1993. Delaume, Chloé. Corpus Simsi. Paris: Éditions Léo Scheer, 2003.Eskelinen, Markku. “The Gaming Situation”. Game Studies 1.1 (2011). <http://www.gamestudies.org/0101/eskelinen/>. Ferguson, Andrew. “Let’s Play Finnegan’s Wake.” Hypermedia Joyce Studies 13 (2014). <http://hjs.ff.cuni.cz/archives/v13_1/main/essays.php?essay=ferguson>. Gadamer, Hans-Georg. Truth and Method, Trans. Barden and Cumming. New York: Crossroad, 1985.Goggin, Joyce. “A Body Hermeneutic?: Corpus Simsi or Reading like a Sim.” The Hand of the Interpreter: Essays on Meaning after Theory. Eds. G.F. Mitrano and Eric Jarosinski. Bern: Peter Lang, 2008. 205-223.Hesse, Hermann. The Glass Bead Game [Das Glasperlenspiel]. Trans. Clara Winston. London: Picador, 2002.Huizinga, Johann. Homo Ludens. Groningen: Wolters-Noordhoff cop, 1938.Hutchinson, Peter. Games Authors Play. New York: Metheun, 1985.James, Joyce. Finnegan’s Wake. London: Faber and Faber, 1939.Morrow, Nancy. Dreadful Games: The Play of Desire and the 19th-Century Novel. Ohio: Kent State UP, 1988.Murray, Janet H. Hamlet on the Holodeck: The Future of Narrative in Cyberspace. Cambridge: MIT UP, 1997.Nabokov, Vladimir. Pale Fire. New York: Putnam, 1962.Ryan, Marie-Laure. Narrative as Virtual Reality: Immersion and Interactivity in Literature and Electronic Media. Baltimore: Johns Hopkins UP, 2001.Saporta, Marc. Composition No. 1. Paris: Éditions du Seuil, 1962.Smith, Grahame. Dickens and the Dream of Cinema. Manchester: Manchester UP, 2003.Spariosu, Mihai. Literature, Mimesis and Play. Tübigen: Gunter Narr Verlag, 1982.Winterson, Janette. The PowerBook. London: Vintage, 2001.Wittgenstein, Ludwig. The Philosophical Investigations. Trans. G.E.M. Anscombe. New York: Macmillan: 1972.

IntroductionOn 4 December 2016, a man entered a Washington, D.C., pizza parlor armed with an AR-15 assault rifle in an attempt to save the victims of an alleged satanic pedophilia ring run by prominent members of the Democratic Party. While the story had already been discredited (LaCapria), at the time of the incident, nearly half of Trump voters were found to give a measure of credence to the same rumors that had apparently inspired the gunman (Frankovic). Was we will discuss here, the bizarre conspiracy theory known as "Pizzagate" had in fact originated a month earlier on 4chan/pol/, a message forum whose very raison d’être is to protest against “political correctness” of the liberal establishment, and which had recently become a hub for “loose coordination” amongst members the insurgent US ‘alt-right’ movement (Hawley 48). Over a period of 25 hours beginning on 3 November 2016, contributors to the /pol/ forum combed through a cache of private e-mails belonging to Hillary Clinton’s campaign manager John Podesta, obtained by Russian hackers (Franceschi-Bicchierai) and leaked by Julian Assange (Wikileaks). In this short time period contributors to the forum thus constructed the basic elements of a narrative that would be amplified by a newly formed “right-wing media network”, in which the “repetition, variation, and circulation” of “repeated falsehoods” may be understood as an “important driver towards a ‘post-truth’ world” (Benkler et al). Heavily promoted by a new class of right-wing pundits on Twitter (Wendling), the case of Pizzagate prompts us to reconsider the presumed progressive valence of social media protest (Zuckerman).While there is literature, both popular and academic, on earlier protest movements associated with 4chan (Stryker; Olson; Coleman; Phillips), there is still a relative paucity of empirical research into the newer forms of alt-right collective action that have emerged from 4chan. And while there have been journalistic exposés tracing the dissemination of the Pizzagate rumors across social media as well as deconstructing its bizarre narrative (Fisher et al.; Aisch; Robb), as of yet there has been no rigorous analysis of the provenance of this particular story. This article thus provides an empirical study of how the Pizzagate conspiracy theory developed out of a particular set of collective action techniques that were in turn shaped by the material affordances of 4chan’s most active message board, the notorious and highly offensive /pol/.Grammatised Collective ActionOur empirical approach is partially inspired by the limited data-scientific literature of 4chan (Bernstein et al.; Hine et al.; Zannettou et al.), and combines close and distant reading techniques to study how the technical design of 4chan ‘grammatises’ new forms of collective action. Our coinage of grammatised collective action is based on the notion of “grammars of action” from the field of critical information studies, which posits the radical idea that innovations in computational systems can also be understood as “ontological advances” (Agre 749), insofar as computation tends to break the flux of human activity into discrete elements. By introducing this concept our intent is not to minimise individual agency, but rather to emphasise the ways in which computational systems can be conceptualised in terms of an individ­ual-milieu dyad where the “individual carries with it a certain inheritance […] animated by all the potentials that characterise [...] the structure of a physical system” (Simondon 306). Our argument is that grammatisation may be thought to create new kinds of niches, or affordances, for new forms of sociality and, crucially, new forms of collective action — in the case of 4chan/pol/, how anonymity and ephemerality may be thought to afford a kind of post-truth protest.Affordance was initially proposed as a means by which to overcome the dualistic tendency, inherited from phenomenology, to bracket the subject from its environment. Thus, affordance is a relational concept “equally a fact of the environment and a fact of behaviour” (Gibson 129). While, in the strictly materialist sense affordances are “always there” (Gibson 132), their capacity to shape action depends upon their discovery and exploitation by particular forms of life that are capable of perceiving them. It is axiomatic within ethology that forms of life can be understood to thrive in their own dynamic, yet in some real sense ontologically distinct, lifeworlds (von Uexküll). Departing from this axiom, affordances can thus be defined, somewhat confusingly but accurately, as an “invariant combination of variables” (Gibson 134). In the case of new media, the same technological object may afford different actions for specific users — for instance, the uses of an online platform appears differently from the perspective of the individual users, businesses, or a developer (Gillespie). Recent literature within the field of new media has sought to engage with this concept of affordance as the methodological basis for attending to “the specificity of platforms” (Bucher and Helmond 242), for example by focussing on how a platform’s affordances may be used as a "mechanism of governance" (Crawford and Gillespie 411), how they may "foster democratic deliberation" (Halpern and Gibbs 1159), and be implicated in the "production of normativity" (Stanfill 1061).As an anonymous and essentially ephemeral peer-produced image-board, 4chan has a quite simple technical design when compared with the dominant social media platforms discussed in the new media literature on affordances. Paradoxically however in the simplicity of their design 4chan boards may be understood to afford rather complex forms of self-expression and of coordinated action amongst their dedicated users, whom refer to themselves as "anons". It has been noted, for example, that the production of provocative Internet memes on 4chan’s /b/ board — the birthplace of Rickrolling — could be understood as a type of "contested cultural capital", whose “media literate” usage allows anons to demonstrate their in-group status in the absence of any persistent reputational capital (Nissenbaum and Shiffman). In order to appreciate how 4chan grammatises action it is thus useful to study its characteristic affordances, the most notable of which is its renowned anonymity. We should thus begin by noting how the design of the site allows anyone to post anything virtually anonymously so long as comments remain on topic for the given board. Indeed, it was this particular affordance that informed the emergence of the collective identity of the hacktivist group “Anonymous”, some ten years before 4chan became publicly associated with the rise of the alt-right.In addition to anonymity the other affordance that makes 4chan particularly unique is ephemerality. As stated, the design of 4chan is quite straightforward. Anons post comments to ongoing threaded discussions, which start with an original post. Threads with the most recent comments appear first in order at the top of a given board, which result in the previous threads getting pushed down the page. Even in the case of the most popular threads 4chan boards only allow a finite number of comments before threads must be purged. As a result of this design, no matter how popular a discussion might be, once having reached the bump-limit threads expire, moving down the front page onto the second and third page either to be temporarily catalogued or else to disappear from the site altogether (see Image 1 for how popular threads on /pol/, represented in red, are purged after reaching the bump-limit).Image 1: 55 minutes of all 4chan/pol/ threads and their positions, sampled every 2 minutes (Hagen)Adding to this ephemerality, general discussion on 4chan is also governed by moderators — this in spite of 4chan’s anarchic reputation — who are uniquely empowered with the ability to effectively kill a thread, or a series of threads. Autosaging, one of the possible techniques available to moderators, is usually only exerted in instances when the discussion is deemed as being off-topic or inappropriate. As a result of the combined affordances, discussions can be extremely rapid and intense — in the case of the creation of Pizzagate, this process took 25 hours (see Tokmetzis for an account based on our research).The combination of 4chan’s unique affordances of anonymity and ephemerality brings us to a third factor that is crucial in order to understand how it is that 4chan anons cooked-up the Pizzagate story: the general thread. This process involves anons combing through previous discussion threads in order to create a new thread that compiles all the salient details on a given topic often archiving this data with services like Pastebin — an online content hosting service usually used to share snippets of code — or Google Docs since the latter tend to be less ephemeral than 4chan.In addition to keeping a conversation alive after a thread has been purged, in the case of Pizzagate we noticed that general threads were crucial to the process of framing those discussions going forward. While multiple general threads might emerge on a given topic, only one will consolidate the ongoing conversation thereby affording significant authority to a single author (as opposed to the anonymous mass) in terms of deciding on which parts of a prior thread to include or exclude. While general threads occur relatively commonly in 4chan, in the case of Pizzagate, this process seemed to take on the form of a real-time collective research effort that we will refer to as bullshit accumulation.The analytic philosopher Harry Frankfurt argues that bullshit is form of knowledge-production that appears unconcerned with objective truth, and as such can be distinguished from misinformation. Frankfurt sees bullshit as “more ambitious” than misinformation defining it as “panoramic rather than particular” since it is also prepared to “fake the context”, which in his estimation makes bullshit a “greater enemy of the truth” than lies (62, 52). Through an investigation into the origins of Pizzagate on /pol/, we thus are able to understand how grammatised collective action assists in the accumulation of bullshit in the service of a kind of post-truth political protest.Bullshit Accumulation4chan has a pragmatic and paradoxical relationship with belief that has be characterised in terms of kind of quasi-religious ironic collectivism (Burton). Because of this "weaponizing [of] irony" (Wilson) it is difficult to objectively determine to what extent anons actually believed that Pizzagate was real, and in a sense it is beside the point. In combination then with the site’s aforementioned affordances, it is this peculiar relationship with the truth which thus makes /pol/ so uniquely productive of bullshit. Image 2: Original pizzagate post on 4chan/pol/When #Pizzagate started trending on Twitter on 4 November 2017, it became clear that much of the narrative, and in particular the ‘pizza connection’, was based on arcane (if not simply ridiculous) interpretations of a cache of e-mails belonging to Hillary Clinton’s campaign manager John Podesta released by Wikileaks during the final weeks of the campaign. While many of the subsequent journalistic exposé would claim that Pizzagate began on 4chan, they did not explore its origins, perhaps because of the fact that 4chan does not consistently archive its threads. Our analysis overcame this obstacle by using a third party archive, Archive4plebs, which allowed us to pinpoint the first instance of a thread (/pol/) that discussed a connection between the keyword “pizza” and the leaked e-mails (Image 2).Image 3: 4chan/pol/ Pizzagate general threadsStarting with the timestamp of the first thread, we identified a total of 18 additional general threads related to the topic of Pizzagate (see Image 3). This establishes a 25-hour timeframe in which the Pizzagate narrative was formed (from Wednesday 2 November 2016, 22:17:20, until Thursday 3 November 2016, 23:24:01). We developed a timeline (Image 4) identifying 13 key moments in the development of the Pizzagate story such as the first attempts at disseminating the narrative to other platforms such as the Reddit forum r/The_Donald a popular forum whose reactionary politics had arguably set the broader tone for the Trump campaign (Heikkila).Image 4: timeline of the birth of Pizzagate. Design by Elena Aversa, information design student at Density Design Lab.The association between the Clinton campaign and pedophilia came from another narrative on 4chan known as ‘Orgy Island’, which alleged the Clintons flew to a secret island for sex tourism aboard a private jet called "Lolita Express" owned by Jeffrey Epstein, an American financier who had served 13 months in prison for soliciting an underage prostitute. As with the Pizzagate story, this narrative also appears to have developed through the shared infrastructure of Pastebin links included in general posts (Pastebin) often alongside Wikileaks links.Image 5: Clues about “pizza” being investigatedOrgy Island and other stories were thus combined together with ‘clues’, many of which were found in the leaked Podesta e-mails, in order to imagine the connections between pedophila and pizza. It was noticed that several of Podesta’s e-mails, for example, mentioned the phrase ‘cheese pizza’ (see Image 5), which on 4chan had long been used as a code word for ‘child pornography’ , the latter which is banned from the site.Image 6: leaked Podesta e-mail from Marina AbramovicIn another leaked e-mail, for example, sent to Podesta from the renowned performance artist Marina Abramovich (see Image 6), a reference to one of her art projects, entitled ‘Spirit Cooking’ — an oblique reference to the mid-century English occultist Aleister Crowley — was interpreted as evidence of Clinton’s involvement in satanic rituals (see Image 7). In the course of this one-day period then, many if not most of the coordinates for the Pizzagate narrative were thus put into place subsequently to be amplified by a new breed of populist social media activists in protest against a corrupt Democratic establishment.Image 7: /pol/ anon’s reaction to the e-mail in Image 6During its initial inception on /pol/, there was the apparent need for visualisations in order make sense of all the data. Quite early on in the process, for example, one anon posted:my brain is exploding trying to organize the connections. Anyone have diagrams of these connections?In response, anons produced numerous conspiratorial visualisations, such as a map featuring all the child-related businesses in the neighbourhood of the D.C. pizza parlor — owned by the boyfriend of the prominent Democratic strategist David Brock — which seemed to have logos of the same general shape as the symbols apparently used by pedophiles, and whose locations seems furthermore to line up in the shape of a satanic pentagram (see Image 8). Such visualisations appear to have served three purposes: they helped anons to identify connections, they helped them circumvent 4chan’s purging process — indeed they were often hosted on third-party sites such as Imgur — and finally they helped anons to ultimately communicate the Pizzagate narrative to a broader audience.Image 8. Anonymously authored Pizzagate map revealing a secret pedophilia network in D.C.By using an inductive approach to categorise the comments in the general threads a set of non-exclusive codes emerged, which can be grouped into five overarching categories: researching, interpreting, soliciting, archiving and publishing. As visualised in Image 9, the techniques used by anons in the genesis of Pizzagate appears as a kind of vernacular rendition of many of the same “digital methods” that we use as Internet researchers. An analysis of these techniques thus helps us to understanding how a grammatised form of collective action arises out of anons’ negotiations with the affordances of 4chan — most notably the constant purging of threads — and how, in special circumstances, this can lead to bullshit accumulation.Image 9: vernacular digital methods on /pol/ ConclusionWhat this analysis ultimately reveals is how 4chan/pol/’s ephemerality affordance contributed to an environment that is remarkably productive of bullshit. As a type of knowledge-accumulation, bullshit confirms preconceived biases through appealing to emotion — this at the expense of the broader shared epistemic principles, an objective notion of “truth” that arguably forms the foundation for public reason in large and complex liberal societies (Lynch). In this sense, the bullshit of Pizzagate resonates with Hannah Arendt’s analysis of totalitarian discourse which nurtures a conspiratorial redefining of emotional truth as “whatever respectable society had hypocritically passed over, or covered with corruption" (49).As right-wing populism establishes itself evermore firmly in many countries in which technocratic liberalism had formerly held sway, the demand for emotionally satisfying post-truth, will surely keep the new online bullshit factories like /pol/ in business. 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Introduction Since December 2010 the dramatic spectacle of the spread of mass uprisings, civil unrest, and protest across North Africa and the Middle East have been chronicled daily on mainstream media and new media. Broadly speaking, the Arab Spring—as it came to be known—is challenging repressive, corrupt governments and calling for democracy and human rights. The convulsive events linked with these debates have been striking not only because of the rapid spread of historically momentous mass protests but also because of the ways in which the media “have become inextricably infused inside them” enabling the global media ecology to perform “an integral part in building and mobilizing support, co-ordinating and defining the protests within different Arab societies as well as trans-nationalizing them” (Cottle 295). Images of mass protests have been juxtaposed against those of individuals prepared to self-destruct for political ends. Video clips and photographs of the individual suffering of Tunisian Mohamed Bouazizi’s self-immolation and the Bahraini Abdulhad al-Khawaja’s emaciated body foreground, in very graphic ways, political struggles that larger events would mask or render invisible. Highlighting broad commonalties does not assume uniformity in patterns of protest and media coverage across the region. There has been considerable variation in the global media coverage and nature of the protests in North Africa and the Middle East (Cottle). In Tunisia, Egypt, Libya, and Yemen uprisings overthrew regimes and leaders. In Syria it has led the country to the brink of civil war. In Bahrain, the regime and its militia violently suppressed peaceful protests. As a wave of protests spread across the Middle East and one government after another toppled in front of 24/7 global media coverage, Bahrain became the “Arab revolution that was abandoned by the Arabs, forsaken by the West … forgotten by the world,” and largely ignored by the global media (Al-Jazeera English). Per capita the protests have been among the largest of the Arab Spring (Human Rights First) and the crackdown as brutal as elsewhere. International organizations have condemned the use of military courts to trial protestors, the detaining of medical staff who had treated the injured, and the use of torture, including the torture of children (Fisher). Bahraini and international human rights organizations have been systematically chronicling these violations of human rights, and posting on Websites distressing images of tortured bodies often with warnings about the graphic depictions viewers are about to see. It was in this context of brutal suppression, global media silence, and the reluctance of the international community to intervene, that the Bahraini-Danish human rights activist Abdulhad al-Khawaja launched his “death or freedom” hunger strike. Even this radical action initially failed to interest international editors who were more focused on Egypt, Libya, and Syria, but media attention rose in response to the Bahrain Formula 1 race in April 2012. Pro-democracy activists pledged “days of rage” to coincide with the race in order to highlight continuing human rights abuses in the kingdom (Turner). As Al Khawaja’s health deteriorated the Bahraini government resisted calls for his release (Article 19) from the Danish government who requested that Al Khawaja be extradited there on “humanitarian grounds” for hospital treatment (Fisk). This article does not explore the geo-politics of the Bahraini struggle or the possible reasons why the international community—in contrast to Syria and Egypt—has been largely silent and reluctant to debate the issues. Important as they are, those remain questions for Middle Eastern specialists to address. In this article I am concerned with the overlapping and interpenetration of two ecologies. The first ecology is the ethical framing of a prison hunger strike as a corporeal-environmental act of (self) destruction intended to achieve political ends. The second ecology is the operation of global media where international inaction inadvertently foregrounds the political struggles that larger events and discourses surrounding Egypt, Libya, and Syria overshadow. What connects these two ecologies is the body of the hunger striker, turned into a spectacle and mediated via a politics of affect that invites a global public to empathise and so enter into his suffering. The connection between the two lies in the emaciated body of the hunger striker. An Ecological Humanities Approach This exploration of two ecologies draws on the ecological humanities and its central premise of connectivity. The ecological humanities critique the traditional binaries in Western thinking between nature and culture; the political and social; them and us; the collective and the individual; mind, body and emotion (Rose & Robin, Rieber). Such binaries create artificial hierarchies, divisions, and conflicts that ultimately impede the ability to respond to crises. Crises are major changes that are “out of control” driven—primarily but not exclusively—by social, political, and cultural forces that unleash “runaway systems with their own dynamics” (Rose & Robin 1). The ecological humanities response to crises is premised on the recognition of the all-inclusive connectivity of organisms, systems, and environments and an ethical commitment to action from within this entanglement. A founding premise of connectivity, first articulated by anthropologist and philosopher Gregory Bateson, is that the “unit of survival is not the individual or the species, but the organism-and-its-environment” (Rose & Robin 2). This highlights a dialectic in which an organism is shaped by and shapes the context in which it finds itself. Or, as Harries-Jones puts it, relations are recursive as “events continually enter into, become entangled with, and then re-enter the universe they describe” (3). This ensures constantly evolving ecosystems but it also means any organism that “deteriorates its environment commits suicide” (Rose & Robin 2) with implications for the others in the eco-system. Bateson’s central premise is that organisms are simultaneously independent, as separate beings, but also interdependent. Interactions are not seen purely as exchanges but as dynamic, dialectical, dialogical, and mutually constitutive. Thus, it is presumed that the destruction or protection of others has consequences for oneself. Another dimension of interactions is multi-modality, which implies that human communication cannot be reduced to a single mode such as words, actions, or images but needs to be understood in the complexity of inter-relations between these (see Rieber 16). Nor can dissemination be reduced to a single technological platform whether this is print, television, Internet, or other media (see Cottle). The final point is that interactions are “biologically grounded but not determined” in that the “cognitive, emotional and volitional processes” underpinning face-to-face or mediated communication are “essentially indivisible” and any attempt to separate them by privileging emotion at the expense of thought, or vice versa, is likely to be unhealthy (Rieber 17). This is most graphically demonstrated in a politically-motivated hunger strike where emotion and volition over-rides the survivalist instinct. The Ecology of a Prison Hunger Strike The radical nature of a hunger strike inevitably gives rise to medico-ethical debates. Hunger strikes entail the voluntary refusal of sustenance by an individual and, when prolonged, such deprivation sets off a chain reaction as the less important components in the internal body systems shut down to protect the brain until even that can no longer be protected (see Basoglu et al). This extreme form of protest—essentially an act of self-destruction—raises ethical issues over whether or not doctors or the state should intervene to save a life for humanitarian or political reasons. In 1975 and 1991, the World Medical Association (WMA) sought to negotiate this by distinguishing between, on the one hand, the mentally/psychological impaired individual who chooses a “voluntary fast” and, on the other hand, the hunger striker who chooses a form of protest action to secure an explicit political goal fully aware of fatal consequences of prolonged action (see Annas, Reyes). This binary enables the WMA to label the action of the mentally impaired suicide while claiming that to do so for political protesters would be a “misconception” because the “striker … does not want to die” but to “live better” by obtaining certain political goals for himself, his group or his country. “If necessary he is willing to sacrifice his life for his case, but the aim is certainly not suicide” (Reyes 11). In practice, the boundaries between suicide and political protest are likely to be much more blurred than this but the medico-ethical binary is important because it informs discourses about what form of intervention is ethically appropriate. In the case of the “suicidal” the WMA legitimises force-feeding by a doctor as a life-saving act. In the case of the political protestor, it is de-legitimised in discourses of an infringement of freedom of expression and an act of torture because of the pain involved (see Annas, Reyes). Philosopher Michel Foucault argued that prison is a key site where the embodied subject is explicitly governed and where the exercising of state power in the act of incarceration means the body of the imprisoned no longer solely belongs to the individual. It is also where the “body’s range of significations” is curtailed, “shaped and invested by the very forces that detain and imprison it” (Pugliese 2). Thus, prison creates the circumstances in which the incarcerated is denied the “usual forms of protest and judicial safeguards” available outside its confines. The consequence is that when presented with conditions that violate core beliefs he/she may view acts of self-destruction—such as hunger strikes or lip sewing—as one of the few “means of protesting against, or demanding attention” or achieving political ends still available to them (Reyes 11; Pugliese). The hunger strike implicates the state, which, in the act of imprisoning, has assumed a measure of power and responsibility for the body of the individual. If a protest action is labelled suicidal by medical professionals—for instance at Guantanamo—then the force-feeding of prisoners can be legitimised within the WMA guidelines (Annas). There is considerable political temptation to do so particularly when the hunger striker has become an icon of resistance to the state, the knowledge of his/her action has transcended prison confines, and the alienating conditions that prompted the action are being widely debated in the media. This poses a two-fold danger for the state. On the one hand, there is the possibility that the slow emaciation and death while imprisoned, if covered by the media, may become a spectacle able to mobilise further resistance that can destabilise the polity. On the other hand, there is the fear that in the act of dying, and the spectacle surrounding death, the hunger striker would have secured the public attention to the very cause they are championing. Central to this is whether or not the act of self-destruction is mediated. It is far from inevitable that the media will cover a hunger strike or do so in ways that enable the hunger striker’s appeal to the emotions of others. However, when it does, the international scrutiny and condemnation that follows may undermine the credibility of the state—as happened with the death of the IRA member Bobby Sands in Northern Ireland (Russell). The Media Ecology and the Bahrain Arab Spring The IRA’s use of an “ancient tactic ... to make a blunt appeal to sympathy and emotion” in the form of the Sands hunger strike was seen as “spectacularly successful in gaining worldwide publicity” (Willis 1). Media ecology has evolved dramatically since then. Over the past 20 years communication flows between the local and the global, traditional media formations (broadcast and print), and new communication media (Internet and mobile phones) have escalated. The interactions of the traditional media have historically shaped and been shaped by more “top-down” “politics of representation” in which the primary relationship is between journalists and competing public relations professionals servicing rival politicians, business or NGOs desire for media attention and framing issues in a way that is favourable or sympathetic to their cause. However, rapidly evolving new media platforms offer bottom up, user-generated content, a politics of connectivity, and mobilization of ordinary people (Cottle 31). However, this distinction has increasingly been seen as offering too rigid a binary to capture the complexity of the interactions between traditional and new media as well as the events they capture. The evolution of both meant their content increasingly overlaps and interpenetrates (see Bennett). New media technologies “add new communicative ingredients into the media ecology mix” (Cottle 31) as well as new forms of political protests and new ways of mobilizing dispersed networks of activists (Juris). Despite their pervasiveness, new media technologies are “unlikely to displace the necessity for coverage in mainstream media”; a feature noted by activist groups who have evolved their own “carnivalesque” tactics (Cottle 32) capable of creating the spectacle that meets television demands for action-driven visuals (Juris). New media provide these groups with the tools to publicise their actions pre- and post-event thereby increasing the possibility that mainstream media might cover their protests. However there is no guarantee that traditional and new media content will overlap and interpenetrate as initial coverage of the Bahrain Arab Spring highlights. Peaceful protests began in February 2011 but were violently quelled often by Saudi, Qatari and UAE militia on behalf of the Bahraini government. Mass arrests were made including that of children and medical personnel who had treated those wounded during the suppression of the protests. What followed were a long series of detentions without trial, military court rulings on civilians, and frequent use of torture in prisons (Human Rights Watch 2012). By the end of 2011, the country had the highest number of political prisoners per capita of any country in the world (Amiri) but received little coverage in the US. The Libyan uprising was afforded the most broadcast time (700 minutes) followed by Egypt (500 minutes), Syria (143), and Bahrain (34) (Lobe). Year-end round-ups of the Arab Spring on the American Broadcasting Corporation ignored Bahrain altogether or mentioned it once in a 21-page feature (Cavell). This was not due to a lack of information because a steady stream has flowed from mobile phones, Internet sites and Twitter as NGOs—Bahraini and international—chronicled in images and first-hand accounts the abuses. However, little of this coverage was picked up by the US-dominated global media. It was in this context that the Bahraini-Danish human rights activist Abdulhad Al Khawaja launched his “freedom or death” hunger strike in protest against the violent suppression of peaceful demonstrations, the treatment of prisoners, and the conduct of the trials. Even this radical action failed to persuade international editors to cover the Bahrain Arab Spring or Al Khawaja’s deteriorating health despite being “one of the most important stories to emerge over the Arab Spring” (Nallu). This began to change in April 2012 as a number of things converged. Formula 1 pressed ahead with the Bahrain Grand Prix, and pro-democracy activists pledged “days of rage” over human rights abuses. As these were violently suppressed, editors on global news desks increasingly questioned the government and Formula 1 “spin” that all was well in the kingdom (see BBC; Turner). Claims by the drivers—many of who were sponsored by the Bahraini government—that this was a sports event, not a political one, were met with derision and journalists more familiar with interviewing superstars were diverted into covering protests because their political counterparts had been denied entry to the country (Fisk). This combination of media events and responses created the attention, interest, and space in which Al Khawaja’s deteriorating condition could become a media spectacle. The Mediated Spectacle of Al Khawaja’s Hunger Strike Journalists who had previously struggled to interest editors in Bahrain and Al Khawaja’s plight found that in the weeks leading up to the Grand Prix and since “his condition rapidly deteriorated”’ and there were “daily updates with stories from CNN to the Hindustan Times” (Nulla). Much of this mainstream news was derived from interviews and tweets from Al Khawaja’s family after each visit or phone call. What emerged was an unprecedented composite—a diary of witnesses to a hunger strike interspersed with the family’s struggles with the authorities to get access to him and their almost tangible fear that the Bahraini government would not relent and he would die. As these fears intensified 48 human rights NGOs called for his release from prison (Article 19) and the Danish government formally requested his extradition for hospital treatment on “humanitarian grounds”. Both were rejected. As if to provide evidence of Al Khawaja’s tenuous hold on life, his family released an image of his emaciated body onto Twitter. This graphic depiction of the corporeal-environmental act of (self) destruction was re-tweeted and posted on countless NGO and news Websites (see Al-Jazeera). It was also juxtaposed against images of multi-million dollar cars circling a race-track, funded by similarly large advertising deals and watched by millions of people around the world on satellite channels. Spectator sport had become a grotesque parody of one man’s struggle to speak of what was going on in Bahrain. In an attempt to silence the criticism the Bahraini government imposed a de facto news blackout denying all access to Al Khawaja in hospital where he had been sent after collapsing. The family’s tweets while he was held incommunicado speak of their raw pain, their desperation to find out if he was still alive, and their grief. They also provided a new source of information, and the refrain “where is alkhawaja,” reverberated on Twitter and in global news outlets (see for instance Der Spiegel, Al-Jazeera). In the days immediately after the race the Danish prime minister called for the release of Al Khawaja, saying he is in a “very critical condition” (Guardian), as did the UN’s Ban-Ki Moon (UN News and Media). The silencing of Al Khawaja had become a discourse of callousness and as global media pressure built Bahraini ministers felt compelled to challenge this on non-Arabic media, claiming Al Khawaja was “eating” and “well”. The Bahraini Prime Minister gave one of his first interviews to the Western media in years in which he denied “AlKhawaja’s health is ‘as bad’ as you say. According to the doctors attending to him on a daily basis, he takes liquids” (Der Spiegel Online). Then, after six days of silence, the family was allowed to visit. They tweeted that while incommunicado he had been restrained and force-fed against his will (Almousawi), a statement almost immediately denied by the military hospital (Lebanon Now). The discourses of silence and callousness were replaced with discourses of “torture” through force-feeding. A month later Al Khawaja’s wife announced he was ending his hunger strike because he was being force-fed by two doctors at the prison, family and friends had urged him to eat again, and he felt the strike had achieved its goal of drawing the world’s attention to Bahrain government’s response to pro-democracy protests (Ahlul Bayt News Agency). Conclusion This article has sought to explore two ecologies. The first is of medico-ethical discourses which construct a prison hunger strike as a corporeal-environmental act of (self) destruction to achieve particular political ends. The second is of shifting engagement within media ecology and the struggle to facilitate interpenetration of content and discourses between mainstream news formations and new media flows of information. I have argued that what connects the two is the body of the hunger striker turned into a spectacle, mediated via a politics of affect which invites empathy and anger to mobilise behind the cause of the hunger striker. The body of the hunger striker is thereby (re)produced as a feature of the twin ecologies of the media environment and the self-environment relationship. References Ahlul Bayt News Agency. “Bahrain: Abdulhadi Alkhawaja’s Statement about Ending his Hunger Strike.” (29 May 2012). 1 June 2012 ‹http://abna.ir/data.asp?lang=3&id=318439›. Al-Akhbar. “Family Concerned Al-Khawaja May Be Being Force Fed.” Al-Akhbar English. (27 April 2012). 1 June 2012 ‹http://english.al-akhbar.com/content/family-concerned-al-khawaja-may-be-being-force-fed›. 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