Zeitschriftenartikel zum Thema „Neglect-like syndrome“

Complex Regional Pain Syndrome (CRPS) is a poorly understood chronic pain condition of multifactorial origin. CRPS involves sensory, motor, and autonomic symptoms primarily affecting one extremity. Patients can also present with neuropsychological changes such as reduced attention to the CRPS-affected extremity, reminiscent of hemispatial neglect, yet in the absence of any brain lesions. However, this “neglect-like” framework is not sufficient to characterise the range of higher cognitive functions that can be altered in CRPS. This comprehensive literature review synthesises evidence of neuropsychological changes in CRPS in the context of potential central mechanisms of the disorder. The affected neuropsychological functions constitute three distinct but not independent groups: distorted body representation, deficits in lateralised spatial cognition, and impairment of non-spatially-lateralised higher cognitive functions. We suggest that many of these symptoms appear to be consistent with a broader disruption to parietal function beyond merely what could be considered “neglect-like.” Moreover, the extent of neuropsychological symptoms might be related to the clinical signs of CRPS, and rehabilitation methods that target the neuropsychological changes can improve clinical outcomes in CRPS and other chronic pain conditions. Based on the limitations and gaps in the reviewed literature, we provide several suggestions to improve further research on neuropsychological changes in chronic pain.

Some names appear to stick to syndromes or diseases like a proverbial glue, regardless of their total inappropriateness. Gross self-neglect in old age characterised by domestic squalor, social withdrawal, apathy, tendency to hoard rubbish (syllogomania) and a lack of shame was originally reported by Macmillan & Shaw in 1966 and subsequently ‘christened’ by Clark et al as Diogenes∗ syndrome in 1975. Post (1982) preferred the term ‘senile recluse’ and argued that this is not a syndrome but merely an end stage of personality disorder. It was usually extremely difficult to help these patients, as one's care and goodwill often met with hostility and blunt refusal to cooperate (Cybulska & Rucinski, 1986). More recent studies, however, have shown a strong association of this condition with frontal lobe dysfunction (Orrell & Sahakian, 1991), thus giving a psychiatrist of old age a somewhat firmer basis for action.

There is evidence to suggest that people with Complex Regional Pain Syndrome (CRPS) can have altered body representations and spatial cognition. One way of studying these cognitive functions is through manual straight ahead (MSA) pointing, in which participants are required to point straight ahead of their perceived body midline without visual feedback of the hand. We therefore compared endpoint errors from MSA pointing between people with CRPS (n = 17) and matched controls (n = 18), and examined the effect of the arm used (Side of Body; affected/non-dominant, non-affected/dominant). For all participants, pointing errors were biased towards the hand being used. We found moderate evidence of no difference between Groups on endpoint errors, and moderate evidence of no interaction with Side of Body. The differences in variability between Groups were non-significant/inconclusive. Correlational analyses showed no evidence of a relationship between MSA endpoint errors and clinical parameters (e.g. CRPS severity, duration, pain) or questionnaire measures (e.g. body representation, “neglect-like symptoms”, upper limb disability). This study is consistent with earlier findings of no difference between people with CRPS and controls on MSA endpoint errors, and is the first to provide statistical evidence of similar performance of these two groups. Our results do not support a relationship between clinical or self-reported measures (e.g. “neglect-like symptoms”) and any directional biases in MSA. Our findings may have implications for understanding neurocognitive changes in CRPS.

On March 30, 1984, I was given the privilege of delivering the introductory speech at the first American Medical Association (AMA) meeting exclusively for child abuse and neglect. Although one might wonder why 22 years lapsed between the Journal of the American Medical Association (JAMA) publication of the milestone article by Henry Kempe1 and the first meeting, the fact remains that the AMA is now paying attention to the needs of abused children and their families. My talk at this conference came just 3 weeks after the death of Henry Kempe, some 20 years almost to the date when he asked if I would like to be involved with his study of the battered child syndrome.

The syndrome of unilateral spatial neglect (USN) after right-hemisphere damage is characterized by failure of salient left-sided stimuli to activate an orienting response, attract attention, and gain access to conscious awareness. The explicit failure processing left-sided visual information is not uniform, however, and patients seem to be more successful performing certain visual tasks than others. The source of this difference is still not clear. We focus on processing of visual scene statistical properties, asking whether, in computing the average size of an array of objects, USN patients give appropriate weight to objects on the left; disregard left-side objects entirely; or assign them an intermediate, lower weight, in accord with their tendency to neglect these objects. The interest in testing this question stems from a series of studies in healthy individuals that led Chong and Treisman [Chong, S. C., & Treisman, A. Statistical processing: Computing the average size in perceptual groups. Vision Research, 45, 891–900, 2005a; Chong, S. C., & Treisman, A. Attentional spread in the statistical processing of visual displays. Perception & Psychophysics, 67, 1–13, 2005b] to propose that processing of statistical properties (like the average size of visual scene elements) is carried out in parallel, with no need for serial allocation of focal attention to the different scene elements. Our results corroborate this suggestion, showing that objects in the left (“neglected”) hemispace contribute to average size computation, despite a marked imbalance in spatial distribution of attention, which leads to a reduced weight of left-side elements in the averaging computation. This finding sheds light on the nature of the impairment in USN and on basic mechanisms underlying statistical processing in vision. We confirm that statistical processing depends mainly on spread-attention mechanisms, which are largely spared in USN.

Abstract: The Smart Infant Baby Monitoring System is an IOT-based project. The goal of this research is to lower SIDS. The primary factor in infant mortality is sudden infant death syndrome. Infants' breathing, temperature, heart rate, and digestion are abnormal. If people neglect infants, they are very likely to die. Monitoring those risk variables on a constant basis helps lower the incidence of SIDS. With the aid of IOT, this clever initiative will enable parents to provide assistance from anywhere, whether they are at home or at work. The idea of wanting and caring for infants, along with the need for sensors and cloud technologies, plays a vital role. The Internet of Things (IOT) and modules like the Raspberry Pi, temperature sensor, MAX30100 sensor, and sound sensor are all integrated into this project.. A temperature sensor measures the body's temperature, a MAX30100 measures the infant's heart rate and SPO2, a sound sensor detects crying, and a camera in a Raspberry Pi module measures body position. With the help of all those data, parents may check on their child's health from anywhere in the world. When the modules notice something abnormal, they immediately send their parents an SMS using cloud technology. By doing this, we can lower the number of SIDS.

Complex approach allows identifying from many-sided positions integrative trends in research of mental health of growing generation. The case in point is evolutionary analysis of risk factors, role of adverse microsocial environment, negative impact of exogenous-organic and endogenous harms. In this aspect of relevance is distinguishing and all-sided development of new branch of the contemporary medicine – micropsychiatry (for this there are interesting basic data on grounding and propriety of description ecological fetal syndrome reflecting, in particular, influence of microdoses of radiation of negative consequences of the Semipalatinsk polygon etc.). Avalanche-like growth of indices of child homelessness and neglect is explained by consequences of microsocial crisis that is experienced by Russian family: this makes extraordinarily relevant problem of social orphanhood. The great attention must be paid to problem of mental health care of participants of pedagogical process (in a-chain-like-way “parent-child-teacher”).Researchers and physicians of child-adolescent subdivision of SI Mental Health Research Institute TSC SB RAMSci conduct work on psychotherapy of childhood and adolescence. In addition, there are many-year results of trials in the field of child-adolescent transculturology, conducted under auspices of the International Association of Ethnopsychologists and Ethnopsychotherapists (with active participation of Siberian scientists and physicians).Efforts of young researchers and representatives of older generation promote the successful development of new media, organizing-medical and preventive technologies allowing resolving the complex of tasks in heightening and mastering “quality of life” of Russian families, strengthening of the individual and societal health of the population of various regions of the country.

Background and purposeDandy Walker “syndrome” (DWS) was firstly defined by Dandy and Blackfan, and then described by Hart et al. [1] as a series of neurodevelopmental anomalies in the posterior fossa, including Dandy-Walker (DW) malformation, DW variant (cerebellar hypoplasia/aplasia of the cerebellar vermis and cystic dilatation of the fourth ventricle), mega-cisterna magna and posterior fossa arachnoid cyst. Mental symptoms have been associated with DWS in previous reports, but the spectrum of mental symptomatology widely varies between clinical cases, ranging from psychotic/schizophrenia-like to mood/cognitive symptoms [2].MethodsHere we describe a case of psychosis and polydrug abuse in a 27-year-old man with DW variant a 4-year history of polydrug abuse, sporadic alcohol abuse, epilepsy and psychotic symptoms including delusions of reference/persecution, suspiciousness, associated with obsessive thoughts, mood lability and persistent anxiety.ResultsHe was recovered for a 28-day program of detoxification from drug addiction/stabilization of psychiatric symptoms. Family history of Bipolar Disorder, gambling disorder (father) and depression (mother). The mental status examination at baseline revealed slowness of thought, psychomotor retardation, aboulia/anhedonia/apathy/hypomimic facies/asthenia/social withdrawal/deflected mood/poor thought content/blunted affect/self-neglect/poor insight, cognitive impairment and oppositive and partially collaborative attitude and behaviour. Borderline intelligence activity was found on WAIS-R (IQ = 79). At the baseline, he was taking carbamazepine 400 mg BID (baseline serum level: 6.720 μg/ml), gabapentin (400 mg BID), paroxetine (20 mg/d), olanzapine (10 mg/d) and methadone (70 ml/d), with a poor response/control both on psychotic and seeking drug symptomatology.References not available.ConclusionsFurther DWS clinical cases should be evaluated in order to better investigate the role of this variant to addictive and psychotic symptoms.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The article summarizes the definition of the term “hikikomori”, analyzes the situation of quarantine restriction: its essence and features of the impact on adolescence. Peculiarities of manifestation of hikikomori markers at adolescence are determined. We consider the studied phenomenon in the system of approaches like a way to meet needs, as a set of manifestations of syndromes of a new era, as a psychological defence mechanism, as a psychological state and process. Depending on the intensity of markers, we divide hikikomori into counter-dependent, poorly adaptable and interdependent, super dependent. The parameters that determine the level of manifestations of hikikomori include antisocial solitude at home, antisocially with leaving the house, selective society. The levels of manifestation of hikikomori include physical, emotional, social. Quarantine restrictions, as unusual living conditions that require forced solitude, selfisolation can be a factor that encourages the emergence of markers of hikikomori in adolescents. Such people have a shift in activity in cyberspace and at night, inseparable stay with the gadget (during meals, in the bathroom, in the toilet, etc.). Neglect of the organization of life (do not clean the bed after sleep, do not clean the room for a long time, do not change clothes during the day and wear night pyjamas around the clock, neglect a healthy diet, eat outside the regime, mostly fast food, etc.). In communication with others, they show irritability with the desire to avoid contact and solitude in their room. Also, at such a person, disorganization of educational activity hastily is observed. It is difficult for them to organize the learning process; they show procrastination (postponement of tasks). If the classes are as videoconferencing, they do not include video and microphone. They are away from contact with the group and the teacher, even if they need contact for feedback, they ignore it. An empirical study of the susceptibility to hikikomori markers in adolescents revealed that about 40% of subjects have a high susceptibility to hikikomori markers, and almost 11% of young men – very high.

Hemispheric asymmetries in affective and cognitive functions have been extensively studied. While both cerebral hemispheres contribute to most affective and cognitive processes, neuroscientific literature and neuropsychological evidence support an overall right hemispheric dominance for emotion, attention and arousal. Emotional stimuli, especially those with survival value such as threat, tend to be prioritized in attentional resource competition. Arousing unpleasant emotional stimuli have prioritized access, especially to right-lateralized attention networks. Interference of task performance may be observed when limited resources are exhausted by task- and emotion-related processing. Tasks that rely on right hemisphere-dependent processing, like attending to the left visual hemifield or global-level visual features, are especially vulnerable to interference due to attention capture by unpleasant emotional stimuli. The aim of this review is to present literature regarding the special role of the right hemisphere in affective and attentional brain processes and their interaction. Furthermore, clinical and technological implications of this interaction will be presented. Initially, the effects of focal right hemisphere lesion or atrophy on emotional functions will be introduced. Neurological right hemisphere syndromes including aprosodia, anosognosia and neglect, which further point to the predominance of the intact right hemisphere in emotion, attention and arousal will be presented. Then there will be a brief review of electrophysiological evidence, as well as evidence from patients with neglect that support attention capture by emotional stimuli in the right hemisphere. Subsequently, experimental work on the interaction of emotion, attention and cognition in the right hemispheres of healthy subjects will be presented. Finally, clinical implications for better understanding and assessment of alterations in emotion–attention interaction due to brain disorder or treatment, such as neuromodulation, that impact affective brain functions will be discussed. It will be suggested that measuring right hemispheric emotion–attention interactions may provide basis for novel biomarkers of brain health. Such biomarkers allow for improved diagnostics in brain damage and disorders and optimized treatments. To conclude, future technological applications will be outlined regarding brain physiology-based measures that reflect engagement of the right hemisphere in affective and attentional processes.

Abstract Objective In addition to pain, people with complex regional pain syndrome (CRPS) often report inattention to and disengagement from their affected limb (i.e., “neglect-like symptoms”). Understanding how these symptoms relate to other characteristics of CRPS, and chronic pain generally, could provide insights for preventing and treating CRPS. Methods We administered an online survey to people who received a diagnosis of CRPS (n = 335) and other chronic limb pain (n = 407). Neglect-like symptoms were assessed using the Neurobehavioral questionnaire. Results A principal component analysis identified two components: motor and cognitive neglect-like symptoms, and involuntary movements. Internal consistency of the components was acceptable. We conducted regression analyses with these as outcomes. Having CRPS, a painful lower limb, higher pain intensity, and somatic symptoms were associated with more motor and cognitive neglect-like symptoms. Having CRPS, higher pain intensity, depression, and somatic symptoms were associated with more involuntary movements. Age, gender, anxiety, disease duration, hours of pain per day, affected side, whether the limb was the most painful body part, and number of pain-related medical diagnoses were no predictors. Finally, motor and cognitive neglect-like symptoms were related to tremor; and involuntary movements to changes in skin color, swelling, sweating, toenails, weakness, and tremor. Conclusions This study confirms the specificity of inattention to and disengagement from the affected limb in CRPS, independent of other factors. Furthermore, two components of the Neurobehavioral questionnaire were disentangled: motor and cognitive neglect-like symptoms, and involuntary movements. Results could potentially help clinicians to better assess neglect-like symptoms in chronic pain.

Abstract Introduction Rapunzel syndrome is a very rare form of trichobezoar. It is strongly linked to psychiatric conditions; trichotillomania and trichophagia. These conditions in the pediatric population point to the presence of childhood stressors like child neglect, abuse, etc. This case report highlights that child neglect may be an underlying contributing factor in selected cases of Rapunzel syndrome. Hence, a multidisciplinary approach should be sought in all cases of Rapunzel syndrome, catering to the emotional and psychological needs of the pediatric population. Case presentation A 7-year-old girl from a low socioeconomic background presented with periorbital and facial swelling, abdominal distension, and pallor. On physical examination, she showed bilateral pitting edema and a distended abdomen with poor overall hygienic condition. Her family history was positive for Wilson’s disease. Lab investigations highlighted iron deficiency anemia (Hb 8.2 g/dL), with normal liver function. Ultrasound demonstrated ascites, liver changes, and pleural effusion. The work-up for Wilson’s disease was unremarkable. During the hospital course, her abdominal distention lessened; a non-tender epigastric mass (4 × 5 cm) was thus discovered. An abdominal X-ray revealed an entangled mass outlining the gastric shadow. Her parents also revealed a history of trichophagia. Suspecting a large trichobezoar, a laparotomy was performed. After the midline incision, the stomach was opened anteriorly between stay sutures along the curvature. It delivered a large trichobezoar, 65 cm in length extending up to the proximal jejunum. Rapunzel syndrome diagnosis was finally established. Conclusion This unique presentation emphasizes the need to consider this rare etiology, even with unusual clinical histories especially with a history of child neglect, while collaborative surgical interventions facilitate successful outcomes.

Child abuse can take many forms like physical abuse, sexual abuse, emotional abuse and Munchausen’s syndrome. It is important to realize that dentist should be aware that such physical and sexual abuse may result in oral and dental injuries or conditions. This review is going to highlight the facts of child abuse and neglect that are overlooked and unnoticed in routine dental practice. Dentists are in an ideal position to detect signs of child abuse because 65% of all physical trauma associated with abuse occurs in the face or neck area. This paper lays emphases on such findings, their significance and to meticulously observe and document them. Furthermore, prominences on key steps in recognizing and reporting abuse while conducting and documenting interviews with the children and parents culminating with discreet cases of abuse related to dentistry.

The major health hazard of the modern world, “Metabolic Syndrome” or “Syndrome X”, defined by WHO, as pathologic condition characterised by abdominal obesity, insulin resistance, hypertension and dyslipidemia [1]. The criteria for diagnosis are listed in Figure 1 [2]. It is being accepted almost a decade ago that we are in the phase of epidemic for this Non Communicable Condition. Though it was started in western world, spread of western lifestyle across the globe, truly it has now become the major global issue. Until recently the condition was far more prevalent in urban population than rural but in today’s time, especially in Country like India, the incidence showed trends towards becoming almost equal [3]. Though recognised all over the world, the condition is rather dealt as managing different component(s) of the syndrome rather than taking the syndrome per say as diagnosis. We rather tend to care much of those patients who actually show prominently one or more components of metabolic syndrome, and this approach is leading us to neglect rather major bulk of patients who, in spite qualifying for criteria of diagnosis of metabolic syndrome, where not only patients are in early asymptomatic phase, but also the physicians caring for them do not reinforce the importance of the needed care at this very moment to prevent or delay the progression of the condition. Healthcare all over world, particularly in India has shown enormous growth, in terms of not only infrastructure but also skill development [4]. Today we do have much better level of expertise in all the subspecialty with regards to high end care of all such conditions arise from one or more components of metabolic syndrome like Heart Failure, Chronic liver disease, chronic kidney disease and Diabetes (related complication). In developing country like India, somewhere 3 to 4 decades ago to subject a patient for liver or kidney transplant used to be mere dream of treating consultants but today we are not only doing the transplants smoothly but also survival rate is getting better and better [5]. But its quiet unfortunate that in spite of all these progresses, the actual numbers of such patients needing high end care is steadily on rise, thanks to increase in life expectancy in general and relatively better exposure to needed healthcare [5]. But author do strongly believe that still whatever we are seeing is more at treatment cum cure level but nothing much at prevention level is going on. In decades to come, we have large population at risk, at this very moment, for all such advanced staged chronic metabolic conditions. We are in genuine need of a molecule which can be offered to all such early or intermediate metabolic syndrome patient, expecting the improvement in almost all the aspect on the syndrome. Author do believe, the group of drugs known as “SGLT2 Inhibitors”, an originally used for Hyperglycemia management, has now expanded its preventive effects on various metabolic conditions, showing promising results in all the trials and early real world evidences, is the real nomination for the “Metabolic Molecule” or “Disease modifying anti metabolic drugs- DMAMDs” of today.

Abstract Background People living with HIV (PLWH) carry a high risk for mental health problems, which has been extensively reported in the literature. However, an understanding of mental health characteristics in different subgroups of PLWH is still limited. In the present study, we conducted a cross-sectional survey to explore mental health characteristics and their associations with childhood trauma in two major subgroups of PLWH in China. Methods A total of 533 PLWH (213 prisoners in the prison system, and 320 outpatients) were assessed using the 8-item Positive Subscale of the Community Assessment of Psychic Experiences (CAPE-P8), Generalized Anxiety Disorder scale (GAD-7), Patient Health Questionnaire (PHQ-9), and Childhood Trauma Questionnaire (CTQ). Results From the total sample, 22.0% PLWH frequently experienced psychotic-like experiences (PLEs), 21.8% had clinically significant anxiety syndrome, 34.0% had clinically significant depressive syndrome, and 63.6% experienced at least one type of traumatic exposure during their childhood, with physical neglect being the most common. Compared to outpatients with HIV, prisoners living with HIV reported more severe mental health problems and a higher frequency of childhood trauma, with childhood trauma in turn predicting higher risk for mental health problems. Similarly, among outpatients living with HIV, both childhood emotional and sexual abuse had predictive effects on all the three mental health problems. Conclusions The study suggests that PLWH have higher risk of anxiety, depression and PLEs, and childhood trauma could serve as predicting factors for such risks. In addition, childhood trauma may play distinct roles in predicting the risk for the mental health problems, depending on different subgroup of PLWH.

With alcohol abuse by pregnant women being a significant problem in South Africa, particularly in the rural areas of the Western Cape province, the country carries one of the world’s heaviest burdens of foetal alcohol syndrome (FAS). FAS is regarded as the most severe of the foetal alcohol spectrum disorders. A child affected by FAS may suffer various developmental delays, including behavioural problems, poor language and fine motor skills, overall poor academic performance, mental retardation, and an increased tendency towards aggression and violence. Despite the alarming extent of the problem, maternal substance abuse is not currently a criminal offence in South Africa. This article explores the feasibility of criminalising maternal substance abuse, either by way of an amendment to the Children’s Act 38 of 2005 or by introducing a new statutory offence. As South African children are already afforded protection against abuse and neglect in terms of the Children’s Act, the prosecution of mothers who abuse substances while pregnant and then give birth to children suffering FAS-related harm could potentially also occur within this ambit. This would require an extension to the definitions of abuse and neglect in the Children’s Act and would have no effect on the legal status of a foetus in South Africa. Yet one would face certain challenges associated with the principle of legality: in terms of the ius strictum requirement, for instance, courts are expected to apply a strict rather than a broad interpretation to the definition of a crime. Therefore, if it is not provided for clearly enough in the definition of abuse and neglect, courts may be hesitant to include maternal substance abuse in their understanding of these crimes. Moreover, a strict interpretation of the meaning of “child” in the Children’s Act would exclude a foetus. In addition, a foetus does not possess legal subjectivity under South African law, which means that it generally does not have any legal rights, nor can it be the victim of any crime. Alternatively, the legislature could opt for introducing a new statutory offence to address maternal substance abuse separately. In this regard, criminalising maternal substance abuse as a materially-defined crime would be the best route to follow. This would restrict prosecution to instances where maternal substance abuse does in fact result in FAS-like effects in the child upon birth. In determining the feasibility of criminalising maternal substance abuse in South Africa, the article also takes a comparative look at United States law in this regard, particularly the position in Alabama and South Carolina. Developments in these states do seem to bode well for a decision to criminalise maternal substance abuse in South Africa as well. As shown in Hicks v State of Alabama 2014 153 So.3d 53 and Whitner v State 328 S.C. 1, 492 S.E.2d 777 (1997), maternal substance abusers in the United States may be prosecuted for either a specific statutory offence or general child neglect. However, while the courts in those cases imposed imprisonment, South Africa’s already overcrowded prisons coupled with the predominantly socio-economic causes of maternal substance abuse in the local context would warrant alternative sentencing options. These include referral to a rehabilitation centre or diversion. In addition, the United States courts seem to have accepted the view that foetuses should be afforded the same protection as children. As this would stir up a hornet’s nest in terms of the abortion debate and the legal status of a foetus in South Africa, following the American example in this respect is not recommended. However, this challenge can be overcome by criminalising maternal substance abuse as suggested above, by providing for prosecution only where the affected child is born alive and presents with FAS-like symptoms.

Abstract: The Coronavirus-19 (COVID-19) hasn’t seen the dawn since its emergence, however waxing and waning has resulted in the emergence of deadly variants. The effects of the pandemic have not been limited to its virulence, but have rather conferred multiple collateral effects, especially in developing countries; thereby, designating it as a SYNDEMIC. The same culminated in neglect of non-COVID-19 conditions like tuberculosis (TB) and human immunodeficiency virus-acquired immunodeficiency syndrome (HIV/AIDS). Besides being the prognostic factor for severe COVID-19, these infections in hidden pockets served as a reservoir for the emergence of the deadly Omicron. Another significant impact of this juxtaposition was on the delivery of healthcare services for TB and HIV. The unanticipated COVID-19 pandemic turned the path of ongoing progress of elimination programs. Direct consequences of the COVID-19 pandemic were pronounced on diagnosis, treatment, and services for patients with TB and HIV. Essential TB services were reallocated to the COVID-19 rapid response task force. However, despite escalating the tribulations, this triple burden has simultaneously taught lessons to escalate the progress of halted programs. The pandemic has catalyzed an unusual level of collaboration among scientists, which can be exploited for TB and HIV. Fast-track diagnostics, digitalization, contact tracing, and vaccine development have enabled the world to envision the same for TB/HIV.

Complex regional pain syndrome type 1 (CRPS Type 1) is a painful and often disabling condition that encompasses an array of complex pathophysiological mechanisms. Along with an assortment of various diagnostic symptoms, CRPS Type 1 generally encompasses pathological centrally and/or peripherally based motor symptoms, including dystonia, bradykinesia, tremor, perceptual and neglect-like symptoms, deconditioning, reduced range of motion, along with others. These motor symptoms can commonly lead their way to movement system dysfunctions. Although irretractable pain is the most frequent and intense symptom experienced in patients with CRPS Type 1, motor symptoms and the movement system are the primary content explored within this paper. Notably, the following review focuses its attention on CRPS Type 1 in the upper extremity of the adult population. The author of this paper has introduced the novel term of the biokinesio-psychosocial model, and is suggested to embrace the movement system in a richer and more inclusive light. The main distinguishing factor between the biopsychosocial model and the biokinesio-psychosocial framework is the introduction of a kinesiological approach towards examining and treating a dysfunctional movement system, specifically in patients with CRPS Type 1. In addition, the review pays attention to biological/ physiological, psychological and social variables that importantly contribute to the diagnosis and treatment of CRPS Type 1. A description of the movement system in relation to CRPS Type 1 is also provided along with an example and critique of a few current existing measures that may be used to assess various motor impairments in patients with CRPS Type 1. Whilst concentrating on the central nervous system as a key perpetrator towards various motor impairments, the review also focuses on psychosocial elements that contribute to the overall experience of a defective movement system in patients with CRPS Type 1. Finally, the review describes the notion of movement system diagnoses or classification systems in relation to CRPS Type 1. With an emphasis on the biokinesio-psychosocial paradigm, 3 newly established movement system diagnoses or classification schemes in relation to adult patients with CRPS Type 1 of the upper extremity, are produced and described in terms of how and when to use them.

Abstract Background Waldenstrom macroglobulinemia (WM) is a rare lymphoma with an incidence rate of 3 per million people per year, with approximately 1000 to 1500 new cases diagnosed each year in the USA. It is primarily seen in Caucasian males with a median age of 70 years old. Patients are most often asymptomatic, but WM can manifest itself with constitutional symptoms such as lethargy, bleeding, organomegaly, and neurological or fundoscopic abnormalities. WM is characterized by immunoglobulin M (IgM) monoclonal gammopathy, lymphocytic infiltration of bone marrow, and normocytic anemia due to bone marrow replacement. Case presentation Our patient is a Hispanic 67-year-old female that presents with one month of intermittent band-like bilateral headache accompanied by dizziness, light-headedness, nausea, and blurred vision. A thorough diagnostic workup was performed, including serum protein electrophoresis (SPEP) with serum immunofixation (SIFE) showing an M spike and IgM kappa. Bone marrow biopsy was significant for lymphoplasmacytic infiltration with nodular B cells (CD19+, CD20+, CD22+). Computerized Tomography (CT) imaging showed splenomegaly in the patient. Treatment was provided for hyperviscosity syndrome with plasmapheresis twice. The patient reported improvement of her symptoms and was then scheduled for chemotherapy. Throughout 7 months, our patient received multiple cycles of bortezomib, dexamethasone, and rituximab. While her symptoms improved her psychiatric status got progressively worse. Conclusion It is important not to neglect symptoms such as a headache, which may seem small, but could serve as a clue in the diagnosis of Waldenstrom's macroglobulinemia.

Artificial Intelligence (AI) refers to the design of computer programs and machines which simulate the rudiments of human intelligence independently [1]. Machine learning encompasses a multitude of deep learning algorithms, including Convolutional Neural Networks (CNN) and Recurrent Neural Networks (RNN) - both of which enable continuous analysis of large-scale data to make decisions consistent with previously detected patterns [1]. AI exhibits high potential for employment in the healthcare industry and research laboratories to accurately predict illness, maximize disease prevention, and refine treatment plans. As technological advancements are made, the application of AI will gradually become more feasible and appropriately lend itself to advancing quality care for frail patients even away from the hospital setting. Frailty is somewhat of an ambiguous diagnosis due to lack of a universally agreed upon definition and frailty assessment tool. Efforts have been put forth to delineate frailty and standardize its method of measurement, but many physicians with minimal to none geriatric experience are more likely to eyeball the patient from the foot end of the bed. Although the Comprehensive Geriatric Assessment (CGA) is a gold standard for multidisciplinary and systematic approach of frailty recognition, it is time-consuming and depends upon administers’ expertise [2]. The integration of AI into a frailty assessment strategy would not only cause a paradigm shift in the approach of physicians to this syndrome, but it would also revolutionize pre-existing protocols for management of frail and pre-frail status patients. Sufficient neglect of the variables that comprise frailty results in inefficacious treatment plans and fuels the cost of patient care. International guidelines have come to appreciate the reversibility of frailty and concur that it should be a mandatory component of patient evaluation [3]. AI may be the solution to pinpointing unidentified vulnerabilities that characterize frailty and ensuring that this entity of geriatric practice is more readily incorporated into other subspecialties, too. Chang et al. (2013) conducted research using “household goods” in hopes of facilitating “early detection of frailty and, hence, its early treatment” [4]. eChair, for example, was used to detect “slowness of movement, weakness and weight loss” [4]. Other devices were featured to detect long-term variations in frailty-determining elements and overall functional decline [4]. Pressure sensors, for example, have been embedded into walkers to measure “risk of fall” [4]. Similarly, Canadian Cardiovascular Society Guidelines (2017) encourage the monitoring of orthostatic vital signs to “identify individuals at risk of falls” [3]. Therefore, gradual integration of AI into day-to-day appliances can be exceptionally beneficial when monitoring patients for development of frailty-like “symptoms”. The authors would like to emphasize that the safety and accuracy of aforementioned AI technologies necessitate careful configuration. Literature unveils the key issues surrounding the safety of AI in healthcare [1]. Addressing these concerns is a top priority because frailty must be handled delicately and demands meticulous planning to eliminate risk factors. The concerns include, but are not limited to, oblivious impact, confidence of prediction, unexpected behaviors, privacy and anonymity [1]. Steps taken for mitigation have been described and, if executed, AI may be utilized to monitor and manage frail patients easily. Models for personalized risk estimates “should be well calibrated and efficient, and effective updating protocols should be implemented” [1]. “Automated systems and algorithms should be able to adjust for and respond to uncertainty and unpredictability” [1]. By centering our focus on the safety and accuracy of AI, we can transform older person’s homes into ‘smart homes’. Smart Homes are equipped with AI-embedded appliances; “networked sensors and devices that extend functionality of the home by adding intelligence” [5]. They collect data for continual analysis and predict potential physiological decline. These advancements would not only improve overall quality of life, but processed data supplements single visits to the primary care provider or geriatrician and eliminates the need for frequent journeys to the physician’s office. In addition, the implementation of AI may pave a pathway for investigating genetic biomarkers associated with increased risk of frailty. Machine learning AI could accelerate research that correlates frailty and Single Nucleotide Polymorphisms (SNP). However, current genetic sequencing technologies remain costly, and sequence processing is time-consuming. Third-generation sequencing technologies, such as Oxford Nanopore’s MinION and PromethION, are more cost-effective and agile solutions [6]. These advantages would make them more accessible and appropriate for use among suspected frail patients. Consequently, identification of SNPs already linked to frailty would be possible through deep RNNs that have been used to distinguish DNA modifications from the sequencing data provided by MinKNOW - the cloud-based platform responsible for data analysis [6,7]. Further advancement of “portable sequencing technology” would promote its use in smart nursing homes - enabling caregivers to closely monitor frailty-susceptible patients and tailoring their care based on the presence of specific SNPs. Ultimately, the authors recommend that the search for underlying risk factors pertinent to frailty commences with: (1) the administration of a simple, yet effective, preliminary frailty assessment in the clinical setting, or (2) opting for installation of AI technology into everydayuse equipment in a controlled environment (such as a smart home). If risk has been determined, (1) a more thorough frailty diagnosing tool may be undertaken by an experienced geriatrician or (2) the decision to undergo an AI-based confirmatory test to assess biomarkers and genetic sequences or (3) a combination of both may be performed.

It was on January 30, 2020 when the World Health Organization (WHO) declared the coronavirus disease 2019 (COVID-19) outbreak a public health emergency of international concern. By March 11, 2020, it was declared a pandemic.1 This was just several weeks after Dr. Li Wenliang, an ophthalmologist from Wuhan, first recognized a possible outbreak of an illness that resembled severe acute respiratory syndrome.2 Over the next three years, we saw the world race against timeto understand the nature of the disease to save those infected and control further transmission across the continents. To date, almost 800 million people, that is, one out of 10 people have been infected, resulting in 7 million deaths worldwide.3,4 In an effort to control the spread of COVID-19, governments imposed lockdown measures. However, this resulted in the de-prioritization of non-communicable diseases including eye diseases as health facilities focused on treating infected patients or implementing vaccination programs. In a report by the WHO, at least 30% of countries had disrupted services for noncommunicable diseases.5 The crisis also resulted in changes in people’s health-seeking behavior, as the fear of COVID-19 outweighed the need for eye care. In the United States, a 60% drop in patient visits for eye care services was reported.6 In fact, the fear of exposure to COVID-19 was found to be associated with a four-fold increased risk of defaulting follow-up.7 Similarly, a study in India and Singapore also reported the fear of COVID-19 infection as a cause of the decline in patient consults.8In response to this crisis, eye care professionals struggled to strike a balance between delivering quality eye care services while mitigating the risk of infection. Various international and local ophthalmologic professional organizations including the American Academy of Ophthalmology,9,10 Philippine Academy of Ophthalmology,11 and the Philippine Society of Cataract and Refractive Surgery12 have issued guidelines on the practice of ophthalmology during the COVID-19 pandemic.These recommendations have become the basis for new standards in eye care. The use of personal protective equipment has become essential at the workplace. Physical barriers such as large slit lamp breath shields and clinic dividers, temperature scanners, alcohol dispensers, and air purifiers with high efficiency particulate air filters have now become common fixtures in most if not all clinics. Changes in clinic processes and protocols have also been adopted to ensure the safety not just of the health care team but also the patients and their families. These include the use of telemedicine where applicable, meticulous patient scheduling, symptom screening prior to clinic visits, enforcement of proper social distancing, disinfection of ophthalmologic equipment, clinic furniture and fixtures, and sterilization of instruments. Even contactless, cashless payment options have now become standard in many facilities. COVID-19 precautions have also become part of ophthalmologic laser and surgical procedure protocols. The pandemic is far from over and it seems that we will have to live with COVID-19 for a very long time. There are many opportunities to improve eye care services by applying the lessons we learned during the pandemic.1. There is no room for complacency. Infection control protocols must remain in place if we are to reassure patients that clinic visits are safe.2. Telemedicine will continue to be an alternative to face-to-face consultations. However, a survey of ophthalmologists reported confidence in using telemedicine for diagnosing gross conditions of the eye but not posterior pole conditions or orbital fractures.13 Improving confidence in telemedicine consults may be accomplished with the use of home monitoring devices such as tonometers and digital applications for various tests including visual acuity, color vision, and visual fields.14 Innovations in home-based ophthalmic imaging will revolutionize tele-ophthalmology, such as the home-optical coherence tomography that may be particularly useful for patients with age-related maculardegeneration and diabetic retinopathy.15Enhancing physician confidence in telemedicine must be paralleled by building patient confidence as well. Technology can disenfranchise certain patient populations like the elderly and those without internet access, and we must continuously strive to reach them and encourage them to try remote consultations when needed. Telemedicine applications should also ensure data privacy and security. 3. Patient education remains crucial in affecting health-seeking behavior. It is important to maximize the utilization of various social media platforms for patient education. As we live in an age of disinformation, we must also remain vigilant against the peddling of wrong or harmful health-related information. In eye care, this may range from cureall eye drops to miracle spectacles to supplements which have no sound scientific basis. Community-based patient education programs and information campaigns may be useful for those without access to digital technologies. 4. It is time to reprioritize ophthalmologic care for patients with non-communicable conditions such as diabetes, hypertension, cancer, and autoimmune diseases. We should also renew collaborative ties with other members of the healthcare team. Many of our patients have suffered worsening of their eye conditions in the past three years, whether by neglect or due to the pandemic-related barriers that prevented their access to timely intervention. Vision is a precious sense that translates very heavily into one’s quality of life. Some of our patients who experienced a decline in their vision during the pandemic – from errors of refraction, cataract, and the like – may be fortunate to have their sight restored in the future. However, our patients suffering from conditions such as glaucoma or proliferative diabetic retinopathy, are in a race against time to control or prevent irreversible visual loss. We move forward with more urgency for their sake, taking our lessons from the pandemic and adapting to this new normal with a renewed commitment to deliver eye care. Kristine Margaret Bacsal-Flores, MD, MBAHClinical Associate ProfessorDepartment of Ophthalmology and Visual SciencesCollege of Medicine and Philippine General HospitalUniversity of the Philippines Manila Felice Katrina T. Ranche, MDAssociate ProfessorDepartment of Ophthalmology and Visual SciencesCollege of Medicine and Philippine General HospitalUniversity of the Philippines Manila REFERENCES 1. World Health Organization [Internet]. WHO Director-General’sopening remarks at the media briefing on COVID-19 - 11 March 2020.2020 Mar 11. [cited 2023 Jan 27]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-openingremarks-at-the-media-briefing-on-covid-19---11-march-2020.2. Green A. Obituary - Li Wenliang. The Lancet. 2020 Feb; 395(10225):682. doi: 10.1016/S0140-6736(20)30382-2.3. World Health Organization [Internet]. WHO Coronavirus(COVID-19) Dashboard. [cited 2023 Jan 27]. Available from:https://covid19.who.int/.4. Worldometers.info [Internet]. Current World Population. [cited2023 Jan 27]. Available from https://www.worldometers.info/worldpopulation/.5. World Health Organization [Internet]. Rapid assessment of servicedelivery for NCDs during the COVID-19 pandemic. 2020 May 29. [cited 2023 Jan 20]. Available from: https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-forncds-during-the-covid-19-pandemic.6. Mehrotra A, Chernew ME, Linetsky D, Hatch H, Cutler DM.The Impact of the COVID-19 Pandemic on Outpatient Visits: ARebound Emerges. 2020 May 19. [cited 2023 Jan 20]. Availablefrom: https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits7. Lindeke-Myers A, Zhao PYC, Meyer BI, Liu EA, Levine DA, Bennett OM, et al. Patient perceptions of SARS-CoV-2 exposure risk andassociation with continuity of ophthalmic care. JAMA Ophthalmol.2021 May; 139(5): 508-15. doi: 10.1001/jamaophthalmol.2021.0114.8. Low R, Lee JM, Lai SS, Rousselot A, Agarwal M, Agrawal R.Eye care during the COVID-19 pandemic: a report on patients’perceptions and experiences, an Asian perspective. Ophthalmol Ther.2022 Feb; 11(1):403-19. doi: 10.1007/s40123-021-00444-0.9. American Academy of Ophthalmology [Internet]. ImportantCoronavirus Updates for Ophthalmologists. 2020 Mar 23. [cited2023 Jan 20]. Available from: https://www.aao.org/headline/alertimportant-coronavirus-context.10. American Academy of Ophthalmology [Internet]. SpecialConsiderations for Ophthalmic Surgery during the COVID-19Pandemic. 2020 May 27. Updated 2021 Mar 22. [cited 2023 Jan 20].Available from: https://www.aao.org/headline/special-considerationsophthalmic-surgery-during-c11. King JH, Aquino JM, Anzures RG, de Leon JMS, Rondaris MVA,Santiago MDD, et al. for the PAO Committee on Standards 2020.COVID-19 guidance on the resumption of eye surgery. PhilippJ Ophthalmol [Internet]. 2021 Jan-Jun [cited 2023 Jan 20];46(1):2-14. Available from: https://paojournal.com/article/covid-19-guidance-on-the-resumption-of-eye-surgery/.12. Naval CG, Cabrera BG for the Philippine Society of Cataract andRefractive Surgery. PSCRS guide to ophthalmic practice in the timesof COVID-19. Philipp J Ophthalmol [Internet]. 2021 Jan-Jun [cited2023 Jan 20];46(1):20-34.. Available from: https://paojournal.com/article/pscrs-guide-to-ophthalmic-practice-in-the-times-of-covid-19/.13. Azarcon CP, Ranche FKT, Santiago DE. Tele-ophthalmologypractices and attitudes in the Philippines in light of the COVID-19pandemic: a survey. Clin Ophthalmol. 2021 Mar; 15:1239-47. doi:10.2147/OPTH.S291790.14. Aruljyothi L, Janakiraman A, Malligarjun B, Babu BM. Smartphoneapplications in ophthalmology: a quantitative analysis. Indian JOphthalmol. 2021 March;69(3):548-53. doi: 10.4103/ijo.IJO_1480_20.15. Miller J, Zeng R. The Future of Home-Based OCT for RetinaPatients. Retina Today [Internet]. 2019 Nov/ Dec; 35-37. [cited2023 Jan 20]. Available from: https://retinatoday.com/articles/2019-nov-dec/the-future-of-home-based-oct-for-retina-patients.

We ask you now, reader, to put your mind, as a citizen of the Australian Commonwealth, to the facts presented in these pages. We ask you to study the problem, in the way that we present the case, from the Aborigines’ point of view. We do not ask for your charity; we do not ask you to study us as scientific-freaks. Above all, we do not ask for your “protection”. No, thanks! We have had 150 years of that! We ask only for justice, decency, and fair play. (Patten and Ferguson 3-4) Jack Patten and William Ferguson’s above declaration on “Plain Speaking” in Aborigines Claim Citizenship Rights! A Statement of the Case for the Aborigines Progressive Association (1938), outlining Aboriginal Australians view of colonisation and the call for Aboriginal self-determinacy, will be my guiding framework in writing this paper. I ask you to study the problem, as it is presented, from the viewpoint of an Indigenous woman who seeks to understand how “sorry” has been uttered in political domains as a word divorced from the moral freight attached to a history of “degrading, humiliating and exterminating” Aboriginal Australians (Patten and Ferguson 11). I wish to argue that the Opposition leader’s utterance of “sorry” in his 13 February 2008 “We Are Sorry – Address to Parliament” was an indicator of the insidious ways in which colonisation has treated Aboriginal Australians as less than, not equal to, white Australians and to examine the ways in which this particular utterance of the word “sorry” is built on longstanding colonial frameworks that position ‘the Aborigine’ as peripheral in the representation of a national identity – a national identity that, as shown by the transcript of the apology, continues to romanticise settler values and ignore Indigenous rights. Nelson’s address tries to disassociate the word “sorry” from any moral attachment. The basis of his address is on constructing a national identity where all injustices are equal. In offering this apology, let us not create one injustice in our attempts to address another. (Nelson) All sorrys are equal, but some are more equal than others. Listening to Nelson’s address, words resembling those of Orwell’s ran through my head. The word “sorry” in relation to Indigenous Australians has taken on cultural, political, educational and economic proportions. The previous government’s refusal to utter the word was attached to the ways in which formations of rhetorically self-sufficient arguments of practicality, equality and justice “functioned to sustain and legitimate existing inequalities between Indigenous and non-Indigenous peoples in Australia” (Augoustinos, LeCouteur and Soyland 105). How then, I wondered as I nervously waited for Nelson to begin apologising, would he transform this inherited collective discursive practice of legitimised racism that upheld mainstream Australia’s social reality? The need for an apology, and the history of political refusal to give it, is not a simple classification of one event, one moment in history. The ‘act’ of removing children is not a singular, one-off event. The need to do, the justification and rationalisation of the doing and what that means now, the having done, as well as the impact on those that were left behind, those that were taken, those that were born after, are all bound up in this particular “sorry”. Given that reluctance of the previous government to admit injustices were done and still exist, this utterance of the word “sorry” from the leader of the opposition precariously sat between freely offering it and reluctantly giving it. The above quote from Nelson, and its central concern of not performing any injustice towards mainstream Australia (“let us not” [my italics]) very definitely defines this sorry in relation to one particular injustice (the removing of Indigenous children) which therefore ignores the surrounding and complicit colonialist and racist attitudes, policies and practices that both institutionalised and perpetuated racism against Australia’s Indigenous peoples. This comment also clearly articulates the opposition’s concern that mainstream Australia not be offended by this act of offering the word “sorry”. Nelson’s address and the ways that it constructs what this “sorry” is for, what it isn’t for, and who it is for, continues to uphold and legitimate existing inequalities between Indigenous and non-Indigenous Australians. From the very start of Nelson’s “We Are Sorry – Address to Parliament”, two specific clarifications were emphasised: the “sorry” was directed at a limited time period in history; and that there is an ‘us’ and a ‘them’. Nelson defines this distinction: “two cultures; one ancient, proud and celebrating its deep bond with this land for some 50,000 years. The other, no less proud, arrived here with little more than visionary hope deeply rooted in gritty determination to build an Australian nation.” This cultural division maintains colonising discourses that define and label, legitimate and exclude groups and communities. It draws from the binary oppositions of self and other, white and black, civilised and primitive. It maintains a divide between the two predominant ideas of history that this country struggles with and it silences those in that space in between, ignoring for example, the effects of colonisation and miscegenation in blurring the lines between ‘primitive’ and ‘civilised’. Although acknowledging that Indigenous Australians inhabited this land for a good few thousand decades before the proud, gritty, determined visionaries of a couple of hundred years ago, the “sorry” that is to be uttered is only in relation to “the first seven decades of the 20th century”. Nelson establishes from the outset that any forthcoming apology, on behalf of “us” – read as non-Indigenous Anglo-Australians – in reference to ‘them’ – “those Aboriginal people forcibly removed” – is only valid for the “period within which these events occurred [which] was one that defined and shaped Australia”. My reading of this sectioning of a period in Australia’s history is that while recognising that certain colonising actions were unjust, specifically in this instance the removal of Indigenous children, this period of time is also seen as influential and significant to the growth of the country. What this does is to allow the important colonial enterprise to subsume the unjust actions by the colonisers by other important colonial actions. Explicit in Nelson’s address is that this particular time frame saw the nation of Australia reach the heights of achievements and is a triumphant period – an approach which extends beyond taking the highs with the lows, and the good with the bad, towards overshadowing any minor ‘unfortunate’ mistakes that might have been made, ‘occasionally’, along the way. Throughout the address, there are continual reminders to the listeners that the “us” should not be placed at a disadvantage in the act of saying “sorry”: to do so would be to create injustice, whereas this “sorry” is strictly about attempting to “address another”. By sectioning off a specific period in the history of colonised Australia, the assumption is that all that happened before 1910 and all that happened after 1970 are “sorry” free. This not only ignores the lead up to the official policy of removal, how it was sanctioned and the aftermath of removal as outlined in The Bringing Them Home Report (1997); it also prevents Indigenous concepts of time from playing a legitimate and recognised role in the construct of both history and society. Aboriginal time is cyclical and moves around important events: those events that are most significant to an individual are held closer than those that are insignificant or mundane. Aleksendar Janca and Clothilde Bullen state that “time is perceived in relation to the socially sanctioned importance of events and is most often identified by stages in life or historic relevance of events” (41). The speech attempts to distinguish between moments and acts in history: firmly placing the act of removing children in a past society and as only one act of injustice amongst many acts of triumph. “Our generation does not own these actions, nor should it feel guilt for what was done in many, but not all cases, with the best of intentions” (Nelson). What was done is still being felt by Indigenous Australians today. And by differentiating between those that committed these actions and “our generation”, the address relies on a linear idea of time, to distance any wrongdoing from present day white Australians. What I struggle with here is that those wrongdoings continue to be felt according to Indigenous concepts of time and therefore these acts are not in a far away past but very much felt in the present. The need to not own these actions further entrenches the idea of separateness between Indigenous Australia and non-Indigenous Australia. The fear of being guilty or at blame evokes notions of wrong and right and this address is at pains not to do that – not to lay blame or evoke shame. Nelson’s address is relying on a national identity that has historically silenced and marginalised Indigenous Australians. If there is no blame to be accepted, if there is no attached shame to be acknowledged (“great pride, but occasionally shame” (Nelson)) and dealt with, then national identity is implicitly one of “discovery”, peaceful settlement and progress. Where are the Aboriginal perspectives of history in this idea of a national identity – then and now? And does this mean that colonialism happened and is now over? State and territory actions upon, against and in exclusion of Indigenous Australians are not actions that can be positioned as past discriminations; they continue today and are a direct result of those that preceded them. Throughout his address, Nelson emphasises the progressiveness of “today” and how that owes its success to the “past”: “In doing so, we reach from within ourselves to our past, those whose lives connect us to it and in deep understanding of its importance to our future”. By relying on a dichotomous approach – us and them, white and black, past and present – Nelson emphasises the distance between this generation of Australia and any momentary unjust actions in the past. The belief is that time moves on – away from the past and towards the future. That advancement, progression and civilisation are linear movements, all heading towards a more enlightened state. “We will be at our best today – and every day – if we pause to place ourselves in the shoes of others, imbued with the imaginative capacity to see this issue through their eyes with decency and respect”. But where is the recognition that today’s experiences, the results of what has been created by the past, are also attached to the need to offer an apology? Nelson’s “we” (Anglo-Australians) are being asked to stop and think about how “they” (Aborigines) might see things differently to the mainstream norm. The implication here also is that “they” – members of the Stolen Generations – must be prepared to understand the position white Australia is coming from, and acknowledge the good that white Australia has achieved. Anglo-Australian pride and achievement is reinforced throughout the address as the basis on which our national identity is understood. Ignoring its exclusion and silencing of the Indigenous Australians to whom his “sorry” is directed, Nelson perpetuates this ideology here in his address: “In brutally harsh conditions, from the small number of early British settlers our non Indigenous ancestors have given us a nation the envy of any in the world”. This gift of a nation where there was none before disregards the acts of invasion, segregation, protection and assimilation that characterise the colonisation of this nation. It also reverts to romanticised settler notions of triumph over great adversities – a notion that could just as easily be attached to Indigenous Australians yet Nelson specifically addresses “our non Indigenous ancestors”. He does add “But Aboriginal Australians made involuntary sacrifices, different but no less important, to make possible the economic and social development of our modern [my emphasis] Australia.” Indigenous Australians certainly made voluntary sacrifices, similar to and different from those made by non Indigenous Australians (Indigenous Australians also went to both World Wars and fought for this nation) and a great deal of “our modern” country’s economic success was achieved on the backs of Blackfellas (Taylor 9). But “involuntary sacrifices” is surely a contradiction in terms, either intellectually shoddy or breathtakingly disingenuous. To make a sacrifice is to do it voluntarily, to give something up for a greater good. “Involuntary sacrifices”, like “collateral damage” and other calculatedly cold-blooded euphemisms, conveniently covers up the question of who was doing what to whom – of who was sacrificed, and by whom. In the attempt to construct a basis of equal contribution between Indigenous and non-Indigenous, as well as equal acts of struggle and triumphing, Nelson’s account of history and nation building draws from the positioning of the oppressors but tries to suppress any notion of racial oppression. It maintains the separateness of Indigenous experiences of colonisation from the colonisers themselves. His reiteration that these occasional acts of unjustness came from benevolent and charitable white Australians privileges non-Indigenous ways of knowing and doing over Indigenous ones and attempts to present them as untainted and innate as opposed to repressive, discriminatory and racist. We honour those in our past who have suffered and all those who have made sacrifices for us by the way we live our lives and shape our nation. Today we recommit to do so – as one people. (Nelson) The political need to identify as “one people” drives assimilation policies (the attitude at the very heart of removing Aboriginal children on the basis that they were Aboriginal and needed to be absorbed into one society of whites). By honouring everyone, and therefore taking the focus off any act of unjustness by non-Indigenous peoples on Indigenous peoples, Nelson’s narrative again upholds an idea of contemporary national identity that has not only romanticised the past but ignores the inequalities of the present day. He spends a good few hundred words reminding his listeners that white Australia deserves to maintain its hard won position. And there is no doubt he is talking to white Australia – his focus is on Western constructs of patriotism and success. He reverts to settler/colonial discourse to uphold ideas of equity and access: These generations considered their responsibilities to their country and one another more important than their rights. They did not buy something until they had saved up for it and values were always more important than value. Living in considerably more difficult times, they had dreams for our nation but little money. Theirs was a mesh of values enshrined in God, King and Country and the belief in something greater than yourself. Neglectful indifference to all they achieved while seeing their actions in the separations only, through the values of our comfortable, modern Australia, will be to diminish ourselves. In “the separations only…” highlights Nelson’s colonial logic, which compartmentalises time, space, people and events and tries to disconnect one colonial act from another. The ideology, attitudes and policies that allowed the taking of Indigenous children were not separate from all other colonial and colonising acts and processes. The desire for a White Australia, a clear cut policy which was in existence at the same time as protection, removal and assimilation policies, cannot be disassociated from either the taking of children or the creation of this “comfortable, modern Australia” today. “Neglectful indifference to all they achieved” could aptly be applied to Indigenous peoples throughout Australian history – pre and post invasion. Where is the active acknowledgment of the denial of Indigenous rights so that “these generations [of non-Indigenous Australians could] consider their responsibilities to their country and one another more important than their rights”? Nelson adheres to the colonialist national narrative to focus on the “positive”, which Patrick Wolfe has argued in his critique of settler colonialism, is an attempt to mask disruptive moments that reveal the scope of state and national power over Aboriginal Australians (33). After consistently reinforcing the colonial/settler narrative, Nelson’s address moves on to insert Indigenous Australians into a well-defined and confined space within a specific chapter of that narrative. His perfunctory overview of the first seven decades of the 20th century alludes to Protection Boards and Reserves, assimilation policies and Christianisation, all underlined with white benevolence. Having established the innocent, inherently humane and decent motivations of “white families”, he resorts to appropriating Indigenous people’s stories and experiences. In the retelling of these stories, two prominent themes in Nelson’s text become apparent. White fellas were only trying to help the poor Blackfella back then, and one need only glance at Aboriginal communities today to see that white fellas are only trying to help the poor Blackfella again. It is reasonably argued that removal from squalor led to better lives – children fed, housed and educated for an adult world of [sic] which they could not have imagined. However, from my life as a family doctor and knowing the impact of my own father’s removal from his unmarried teenaged mother, not knowing who you are is the source of deep, scarring sorrows the real meaning of which can be known only to those who have endured it. No one should bring a sense of moral superiority to this debate in seeking to diminish the view that good was being sought to be done. (Nelson) A sense of moral superiority is what motivates colonisation: it is what motivated the enforced removal of children. The reference to “removal from squalor” is somewhat reminiscent of the 1909 Aborigines Protection Act. Act No. 25, 1909, section 11(1) which states: The board may, in accordance with and subject to the provisions of the Apprentices Act, 1901, by indenture bind or cause to be bound the child of any aborigine, or the neglected child of any person apparently having an admixture of aboriginal blood in his veins, to be apprenticed to any master, and may collect and institute proceedings for the recovery of any wages payable under such indenture, and may expend the same as the board may think fit in the interest of the child. Every child so apprenticed shall be under the supervision of the board, or of such person that may be authorised in that behalf by the regulations. (144) Neglect was often defined as simply being Aboriginal. The representation that being removed would lead to a better life relies on Western attitudes about society and culture. It dismisses any notion of Indigenous rights to be Indigenous and defines a better life according to how white society views it. Throughout most of the 1900s, Aboriginal children that were removed to experience this better life were trained in positions of servants. Nelson’s inclusion of his own personal experience as a non Indigenous Australian who has experienced loss and sorrow sustains his textual purpose to reduce human experiences to a common ground, an equal footing – to make all injustices equal. And he finishes the paragraph off with the subtle reminder that this “sorry” is only for “those” Aboriginal Australians that were removed in the first seven decades of last century. After retelling the experience of one Indigenous person as told to the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families, he retells the experience of an Indigenous woman as told to a non-Indigenous man. The appropriate protocols concerning the re-using of Indigenous knowledge and intellectual copyright appeared to be absent in this address. Not only does the individual remain unacknowledged but the potential for misappropriating Indigenous experiences for non Indigenous purposes is apparent. The insertion of the story dismisses the importance of the original act of telling, and the significance of the unspeakable through decades of silence. Felman presents the complexities of the survivor’s tale: “the victim’s story has to overcome not just the silence of the dead but the indelible coercive power of the oppressor’s terrifying, brutal silencing of the surviving, and the inherent speechless silence of the living in the face of an unthinkable, unknowable, ungraspable event” (227). In telling this story Nelson unravelled the foundation of equality he had attempted to resurrect. And his indication towards current happenings in the Northern Territory only served to further highlight the inequities that Indigenous peoples continue to face, resist and surpass. Nelson’s statement that “separation was then, and remains today, a painful but necessary part of public policy in the protection of children” is another reminder of the “indelible coercive power of the oppressor’s terrifying” potential to repeat history. The final unmasking of the hypocritical and contested nature of Nelson’s national ideology and narrative is in his telling of the “facts” – the statistics concerning Indigenous life expectancy, Indigenous infant mortality rates, “diabetes, kidney disease, hospitalisation of women from assault, imprisonment, overcrowding, educational underperformance and unemployment”. These statistics are a result not of what Nelson terms “existential aimlessness” (immediately preceding paragraph) but of colonisation – theft of land, oppression, abuse, discrimination, and lack of any rights whether citizenship or Aboriginal. These contemporary experiences of Indigenous peoples are the direct linear result of the last two hundred years of white nation building. The address is concluded with mention of Neville Bonner, portrayed here as the perfect example of what reading, writing, expressing yourself with dignity and treating people with decency and courtesy can achieve. Bonner is presented as the ‘ideal’ Blackfella, a product of the assimilation period: he could read and write and was dignified, decent and courteous (and, coincidentally, Liberal). The inclusion of this reference to Bonner in the address may hint at the “My best friend is an Aborigine” syndrome (Heiss 71), but it also provides a discursive example to the listener of the ways in which ‘equalness’ is suggested, assumed, privileged or denied. It is a reminder, in the same vein of Patten and Ferguson’s fights for rights, that what is equal has always been apparent to the colonised. Your present official attitude is one of prejudice and misunderstanding … we are no more dirty, lazy stupid, criminal, or immoral than yourselves. Also, your slanders against our race are a moral lie, told to throw all the blame for your troubles on to us. You, who originally conquered us by guns against our spears, now rely on superiority of numbers to support your false claims of moral and intellectual superiority. After 150 years, we ask you to review the situation and give us a fair deal – a New Deal for Aborigines. The cards have been stacked against us, and we now ask you to play the game like decent Australians. Remember, we do not ask for charity, we ask for justice. Nelson quotes Bonner’s words that “[unjust hardships] can only be changed when people of non Aboriginal extraction are prepared to listen, to hear what Aboriginal people are saying and then work with us to achieve those ends”. The need for non-Indigenous Australians to listen, to be shaken out of their complacent equalness appears to have gone unheard. Fiumara, in her philosophy of listening, states: “at this point the opportunity is offered for becoming aware that the compulsion to win is due less to the intrinsic difficulty of the situation than to inhibitions induced by a non-listening language that prevents us from seeing that which would otherwise be clear” (198). It is this compulsion to win, or to at least not be seen to be losing that contributes to the unequalness of this particular “sorry” and the need to construct an equal footing. This particular utterance of sorry does not come from an acknowledged place of difference and its attached history of colonisation; instead it strives to create a foundation based on a lack of anyone being positioned on the high moral ground. It is an irony that pervades the address considering it was the coloniser’s belief in his/her moral superiority that took the first child to begin with. Nelson’s address attempts to construct the utterance of “sorry”, and its intended meaning in this specific context, on ‘equal’ ground: his representation is that we are all Australians, “us” and ‘them’ combined, “we” all suffered and made sacrifices; “we” all deserve respect and equal acknowledgment of the contribution “we” all made to this “enviable” nation. And therein lies the unequalness, the inequality, the injustice, of this particular “sorry”. This particular “sorry” is born from and maintains the structures, policies, discourses and language that led to the taking of Indigenous children in the first place. In his attempt to create a “sorry” that drew equally from the “charitable” as well as the “misjudged” deeds of white Australia, Nelson’s “We Are Sorry – Address to Parliament” increased the experiences of inequality. Chow writes that in the politics of admittance the equal depends on “acceptance by permission … and yet, being ‘admitted’ is never simply a matter of possessing the right permit, for validation and acknowledgment must also be present for admittance to be complete” (36-37). References Augoustinos, Martha, Amanda LeCouteur, and John Soyland. “Self-Sufficient Arguments in Political Rhetoric: Constructing Reconciliation and Apologizing to the Stolen Generations.” Discourse and Society 13.1 (2002): 105-142.Bringing Them Home: National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families. Sydney: Human Rights and Equal Opportunity Commission, 1997.Aborigines Protection Act 1909: An Act to Provide for the Protection and Care of Aborigines; To Repeal the Supply of Liquors Aborigines Prevention Act; To Amend the Vagrancy Act, 1902, and the Police Offences (Amendment) Act, 1908; And for Purposes Consequent Thereon or Incidental Thereto. 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I’m Not a Racist But… UK: Salt Publishing, 2007.Janca, Aleksandar, and Clothilde Bullen. “Aboriginal Concept of Time and Its Mental Health Implications.” Australian Psychiatry 11 (Supplement 2003): 40-44.Nelson, Brendan. “We Are Sorry – Address to Parliament.” 14 Feb. 2008 < http://www.liberal.org.au/info/news/detail/20080213_ WearesorryAddresstoParliament.php >.Patten, Jack, and William Ferguson. Aborigines Claim Citizen Rights! A Statement for the Aborigines Progressive Association. Sydney: The Publicist, 1938.Taylor, Martin, and James Francis. Bludgers in Grass Castles: Native Title and the Unpaid Debts of the Pastoral Industry. Chippendale: Resistance Books, 1997.William, Ross. “‘Why Should I Feel Guilty?’ Reflections on the Workings of White-Aboriginal Relations.” Australian Psychologist 35.2 (2000): 136-142.Wolfe, Patrick. Settler Colonialism and the Transformation of Anthropology: The Politics and Poetics of an Ethnographic Event. London and New York: Cassell, 1999.