Journal articles on the topic 'Martin Van Buren'

Abstract Starting with Andrew Jackson, presidential candidates in the United States used campaign biographies as useful political tools, and since 1824 no presidential election year has passed without a campaign biography. Martin Van Buren, President Jackson’s successor in the White House, became a target of a vicious campaign intended to prevent his election. His Whig opponents used a number of literary genres to slander him, including a mock campaign biography and a novel. The article focuses on the portrayal of Martin Van Buren in The Life of Martin Van Buren, allegedly written by Davy Crockett in 1835, and a novel named The Partisan Leader; A Tale of the Future, written by Nathaniel Beverley Tucker in 1836. Though being of different genres, these curious and obscure works have certain things in common - they were written under pseudonyms, their main goal was to prevent the election of Martin Van Buren and both of them failed in their goal.

THE ELECTION OF GEORGE BUSH TO THE PRESIDENCY IN 1988 was a triumph for Ronald Reagan. The margin of victory was substantial (54 per cent to Bush over 46 per cent to Michael Dukakis in the popular vote) — though not of Reaganesque proportions. But then the master might not wish his apprentice to do as well as himself. Reagan has not only brought peace and prosperity in his own terms while in office, but also has succeeded in leaving a legacy. And the legacy is not only in the political changes he instituted but partly in the person of his immediate successor, the first vicepresident to succeed as president by election since Martin Van Buren in 1837.

In the nineteenth century, the Mormons were a minority religious group living on the fringes of the United States in both a geographic and social sense. Yet, in the twenty-first century, historians are increasingly realizing that the history of this marginal religious “other” sheds a great deal of light on the American past broadly conceived. This essay briefly describes an important moment in early Mormon history that illuminates our developing understanding of religious liberty in the early American republic, and the political obstacles Americans outside mainstream protestant Christianity faced in their efforts to obtain equal treatment under the law as American citizens.

Background:Acute anterior uveitis (AAU), inflammation of the anterior uveal tract, is reported in up to 40% of patients (pts) with axial spondyloarthritis (axSpA).1AAU is associated with significant clinical burden; symptoms include blurred vision, photophobia and pain.2Previous studies have shown that TNF inhibitors (TNFi) can reduce AAU flare incidence in pts with radiographic axSpA,3-5but few have focused on pts across the full axSpA spectrum.Objectives:To analyse the impact of certolizumab pegol (CZP) treatment on AAU in pts with active radiographic and non-radiographic axSpA and a recent history of AAU.Methods:C-VIEW (NCT03020992) is an ongoing multicentre, open-label, phase 4 study. Pts had active axSpA according to the ASAS classification, a history of recurrent AAU (≥2 AAU flares in total and ≥1 AAU flare in the year prior to study entry), were HLA-B27 positive, and were eligible for TNFi treatment (previous failure of ≥2 NSAIDs, biologic naïve or had failed ≤1 TNFi). Pts received CZP 400 mg at Weeks (Wks) 0/2/4, then 200 mg every two wks (Q2W) to Wk 96. The primary variable was incidence of AAU flares compared to historic rates. A pre-specified interim analysis compared AAU incidence in the 48 wks prior to CZP treatment with the 48 wks of treatment, using Poisson regression adjusted for possible within-pt correlations, with period (pre- and post-baseline) and axSpA disease duration as covariates. Incidence rates (IR) were calculated based on the number of cases/pts at risk over 48 wks. Observed data are reported.Results:Of 115 enrolled pts, 89 initiated CZP treatment; 85 completed Wk 48. Baseline characteristics are shown in the Table. The 48-wk interim analysis revealed significantly fewer AAU flares/pt during CZP treatment vs before treatment (Figure; Poisson-adjusted IR: 0.2 vs 1.5, p<0.001). The number of pts experiencing 1 and ≥2 AAU flares (64.0% and 31.5% respectively) substantially reduced during CZP treatment (12.4% and 2.2%). After 48 wks CZP treatment, disease activity improved substantially (mean ± SD Ankylosing Spondylitis Disease Activity Score [ASDAS]: 2.0 ± 0.9; Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]: 3.3 ± 2.1), with 31.4% pts achieving ASAS partial remission and 29.1% ASDAS major improvement. No new safety signals were identified.Table.Baseline characteristicsCZP 200 mg Q2W (N=89)Age (years), mean ± SD46.5 ± 11.2Male, n (%)56 (62.9)Racial group, n (%) Caucasian87 (97.8) Other2 (2.2)Diagnosis, n (%) Radiographic axSpA76 (85.4) Non-radiographic axSpA13 (14.6)Duration of axSpA (years), mean ± SD8.6 ± 8.4Time since onset of first uveitis flare (years), mean ± SD9.9 ± 9.0ASDAS, mean ± SD3.5 ± 0.9BASDAI, mean ± SD6.5 ± 1.5Conclusion:In this open-label study, AAU flare rate significantly reduced in axSpA pts with a history of recurrent AAU during the first 48 wks of CZP. Pts also experienced substantial improvements in axSpA disease activity.References:[1]Martin TM. Curr Opin Rheumatol 2002;14:337–41[2]Bacchiega ABS. Rheumatology (Oxford) 2017;56:2060–7[3]van der Heijde D. Rheumatology (Oxford) 2017;56:1498–509[4]van Bentum RE. J Rheumatol 2019;46:153–9[5]van Denderen JC. J Rheumatol 2014;41:1843–8Acknowledgments:This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.Disclosure of Interests:Irene van der Horst-Bruinsma Grant/research support from: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Rianne van Bentum: None declared, Frank Verbraak Grant/research support from: Bayer, Novartis, IDxDR, UCB Pharma, Consultant of: Bayer, Novartis, IDxDR, UCB Pharma, Thomas Rath Grant/research support from: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, James Rosenbaum Consultant of: AbbVie, Corvus, Eyevensys, Gilead, Novartis, Janssen, Roche, UCB Pharma; royalties from UpToDate, Maria Misterska-Skora: None declared, Bengt Hoepken Employee of: UCB Pharma, Oscar Irvin-Sellers Employee of: UCB Pharma, Brenda VanLunen Employee of: UCB Pharma, Lars Bauer Employee of: UCB Pharma, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma

Although not elected to the office, Gerald Ford nonetheless had the opportunity to change the nation's course in Vietnam when he assumed the presidency in August 1974. He did not do so, leaving the burden of ending the war there to the U.S. Congress. Contrary to what some policymakers and historians have subsequently argued, Congress did not sell out a healthy, viable South Vietnamese government to the communists in 1974––1975. Instead, the senators and representatives who voted to reduce, not cut off, military and economic assistance to the government of Nguyen Van Thieu made the correct and proper decision in the face of that regime's obviously untenable nature and the overwhelming desire of the American people to curtail support for it. Rather than working out a plan to end the war and remove those South Vietnamese who had worked with the Americans over the years, the Ford administration, led by the President himself, his Secretary of State and National Security Adviser Henry Kissinger, and Graham Martin, the U.S. ambassador to South Vietnam, chose to pursue a deliberate policy of denial, one designed to place the blame for the loss of South Vietnam on the shoulders of Congress. The resulting tragedy left thousands of Vietnamese to face life as the clear losers in a civil war.

Background:Acute anterior uveitis (AAU) is the most common extra-articular manifestation in axial spondyloarthritis (axSpA), affecting up to 40% of patients and causing significant burden.1 Previous studies have shown that tumour necrosis factor inhibitors (TNFi) can reduce the incidence of AAU flares in patients with radiographic axSpA (ankylosing spondylitis),2-4 but few have focused on patients across the full axSpA spectrum.1Objectives:To report 2-year outcomes from the phase 4, open-label C-VIEW study (NCT03020992), which investigated the impact of certolizumab pegol (CZP) treatment on AAU in patients with active axSpA and a recent history of AAU.Methods:C-VIEW prospectively investigated patients with active axSpA who were HLA-B27 positive and had recurrent AAU, with a history of ≥1 AAU flare in the year prior to baseline (additional study criteria and study design are described elsewhere5). The primary efficacy variable was the incidence of AAU flares during 96 weeks of CZP treatment versus the 2-year pre-baseline period. AAU incidence was evaluated using Poisson regression adjusted for duration of time in each period, with period (pre- and post-baseline) and axSpA disease duration as covariates. Secondary efficacy variables were Assessment of SpondyloArthritis international Society 20%/40% (ASAS20/40) response rates, as well as mean Ankylosing Spondylitis Disease Activity Score (ASDAS) and mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) to Week 96.Results:Of 115 enrolled patients, 89 initiated CZP treatment; 83 completed Week 96. The primary analysis revealed an 82% reduction in the incidence of AAU flares during CZP treatment compared with pre-baseline (Figure 1A; rate ratio [95% CI]: 0.18 [0.12, 0.28], p<0.001). The percentage of patients experiencing ≥1 and ≥2 AAU flares reduced from 100% and 59.6% pre-baseline to 20.2% and 11.2% during treatment (Figure 1B). There were also improvements in axSpA disease activity (Table 1): by Week 96, 75.6% and 58.5% of patients had achieved ASAS20 and ASAS40 responses, respectively. ASDAS and BASDAI also improved substantially over the 96-week treatment period. No new safety signal was identified, compared to previous reports.5Conclusion:These data support the use of CZP for the treatment of patients with axSpA and a history of recurrent AAU. During 96 weeks’ CZP treatment, there was a significant reduction of 82% in the AAU flare rate compared to pre-baseline. There were also substantial improvements in patients’ axSpA disease activity.References:[1]Martin TM. Curr Opin Rheumatol 2002;14:337–41.[2]van der Heijde D. Rheumatology (Oxford) 2017;56:1498–509.[3]van Bentum RE. J Rheumatol 2019;46:153–9.[4]van Denderen JC. J Rheumatol 2014;41:1843–8.[5]van der Horst-Bruinsma I. RMD Open 2020;6:e001161.Table 1.Changes in axSpA disease activity to Week 96Disease activity measureWeek 0(n=89)Week 48(n=86)Week 96(n=82)ASAS responder rates, n (%)ASAS20N/A65 (75.6)62 (75.6)ASAS40N/A46 (53.5)48 (58.5)ASDAS, mean (SD)3.5 (1.0)2.0 (0.9)1.9 (1.0)BASDAI, mean (SD)6.5 (1.5)3.3 (2.1)3.0 (2.1)Observed data are shown. Patients received CZP 400 mg at Weeks 0/2/4, then 200 mg Q2W through 96 weeks. ASAS20/40: Assessment of SpondyloArthritis international Society 20%/40%; ASDAS: Ankylosing Spondylitis Disease Activity Score; axSpA: axial spondyloarthritis; BASDAI: Bath Ankylosing Spondylitis Disease Activity Index; CZP: certolizumab pegol; Q2W: every 2 weeks; SD: standard deviation.Acknowledgements:This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.Disclosure of Interests:Irene van der Horst-Bruinsma Speakers bureau: AbbVie, BMS, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, UCB Pharma, Grant/research support from: AbbVie, MSD, Pfizer, Rianne van Bentum: None declared, Frank Verbraak Speakers bureau: Bayer, IDxDR, Novartis, UMC, Consultant of: Bayer, Novartis, Grant/research support from: Bayer, Thomas Rath Speakers bureau: AbbVie, BMS, Chugai, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Consultant of: AbbVie, BMS, Chugai, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Bengt Hoepken Shareholder of: UBC Pharma, Employee of: UCB Pharma, Oscar Irvin-Sellers Shareholder of: UCB Pharma, Employee of: UCB Pharma, Thomas Kumke Shareholder of: UCB Pharma, Employee of: UCB Pharma, Lars Bauer Shareholder of: UCB Pharma, Employee of: UCB Pharma, Martin Rudwaleit Speakers bureau: AbbVie, Eli Lilly, Novartis, UCB Pharma, Consultant of: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, UCB Pharma

Background:Chronic fatigue is a well-known symptom in patients with rheumatic diseases and other immune-mediated inflammatory diseases (IMIDs). Therefore, fatigue as an adverse drug reaction (ADR) to biologics may remain unrecognised or may erroneously be attributed to the disease.Objectives:To assess patient-reported fatigue attributed to biologics for IMIDs and investigate predisposing factors of patient-reported fatigue.Methods:The Dutch Biologic Monitor is a multicenter patient-reported ADR monitoring system that surveys patients using a biologic for an IMID. Patients completed web-based questionnaires regarding ADRs attributed to biologics and the course and experienced burden (5 point Likert scale) of these ADRs. All patient-reported ADRs with MedDRA Preferred Term ‘fatigue’ were defined as biologic-associated fatigue (BA-fatigue). Basic demographics and treatment characteristics were compared between patients reporting BA-fatigue and patients not reporting BA-fatigue (reported other ADRs or no ADRs).Results:Out of 1369 participating IMID patients, 696 patients reported 1844 unique ADRs. BA-fatigue was reported by 100 patients and 48 patients described a consistent pattern of recurring fatigue after each administration. Most of these patients (88%) described recovery from BA-fatigue within one week after biologic administration and 73 patients reported health care professional (HCP) contact following BA-fatigue, with dose adjustment in 8 and discontinuation in 5 patients.Basic demographics and characteristics that differ significantly between patients reporting BA-fatigue and patients not reporting BA-fatigue are summarized in table 1. No significant difference was found for other biologics, IMIDs, combination therapy and comorbidities. BA-fatigue was reported by 27% of rituximab users (n=33), 27% of vedolizumab users (n=26), 16% of tocilizumab users (n=50), 14% of infliximab users (n=159) and 3% of etanercept users (n=418). Although 29 patients in the BA-fatigue population had RA and 29 patients had Crohn’s disease (CD), 571 patients in our overall study population had RA and 194 patients had CD, suggesting BA-fatigue was reported by CD patients more often. The mean burden of BA-fatigue was higher than the mean burden of other ADRs (p<0.001).Table 1.Characteristics of patients with BA-fatigue compared to patients with other ADRs and without ADRsPatients with BA-fatigue n (%)Patients with other ADRs n (%)Patients without ADRs n (%)n100 (100%)596 (100%)673 (100%)Basic demographicsAge (years) (mean ± SD)50.0 ± 14.653.4 ± 13.6 *55.7 ± 14.2 ***Gender (Female)59 (59%)398 (67%)ns342 (51%)nsSmoking n (%)25 (25%)97 (16%) *100 (15%) *BMI (kg/m2) (mean ± SD)25.7 ± 4.425.9 ± 4.7ns26.6 ± 5.5nsBiologicInfliximab22 (22%)53 (9%) ***84 (12%) *Etanercept13 (13%)177 (30%) ***228 (34%) ***Rituximab9 (9%)18 (3%) **6 (1%) ***Tocilizumab8 (8%)29 (5%)ns13 (2%) **Vedolizumab7 (7%)12 (2%) *7 (1%) ***IMIDRheumatoid arthritis29 (29%)270 (45%) **272 (40%) *Crohn’s disease29 (29%)77 (13%) ***88 (13%) ***Other indication16 (16%)53 (9%) *39 (6%) ***Combination therapyMethotrexate23 (23%)167 (28%)ns227 (34%) *ComorbidityPsychiatric disorder11 (11%)49 (8%)ns31 (5%) *Other comorbidity30 (30%)124 (21%) *102 (15%) ***Mean burden of ADR ± SD2.9 ± 0.92.4 ± 1.1 ***Mann Whitney U, independent t-test and Fisher’s exact as appropriatens: not significant *p ≤ 0.05 **p ≤ 0.01 ***p ≤ 0.001Conclusion:HCPs should be aware that fatigue may be associated with biologic therapy and has a significant burden on patients. Evaluating the course of the symptoms might be helpful in recognizing BA-fatigue.Disclosure of Interests:Jette van Lint: None declared, Tom Bakker: None declared, Jouke Ubbink: None declared, Martijn van Doorn Grant/research support from: Unrestricted grants, advisory board, speaker fees and/or other (investigator) from Novartis, Abbvie, Janssen Cilag, Leopharma and Pfizer, Speakers bureau: Unrestricted grants, advisory board, speaker fees and/or other (investigator) from Novartis, Abbvie, Janssen Cilag, Leopharma and Pfizer, Phyllis Spuls Grant/research support from: Departmental independent research grant for TREAT NL registry LeoPharma December 2019; Contract support: I am involved in performing clinical trials with many pharmaceutical industries that manufacture drugs used for the treatment of e.g. psoriasis and atopic dermatitis for which we get financial compensation paid to the department/hospital, Consultant of: Consultancies in the past for Sanofi 111017 and AbbVie 041217 (unpaid), Sander Tas: None declared, Harald Vonkeman: None declared, Frank Hoentjen Grant/research support from: Received grants from Dr Falk, Janssen-Cilag, and AbbVie., Consultant of: Served on advisory boards, or as speaker or consultant for AbbVie, Celgene, Janssen-Cilag, MSD, Takeda, Celltrion, Teva, Sandoz, and Dr Falk, Speakers bureau: Served on advisory boards, or as speaker or consultant for AbbVie, Celgene, Janssen-Cilag, MSD, Takeda, Celltrion, Teva, Sandoz, and Dr Falk, Bart van den Bemt Grant/research support from: UCB, Pfizer and Abbvie, Consultant of: Delivered consultancy work for UCB, Novartis and Pfizer, Speakers bureau: Pfizer, AbbVie, UCB, Biogen and Sandoz., Michael Nurmohamed Grant/research support from: Not related to this research, Consultant of: Not related to this research, Speakers bureau: Not related to this research, Eugène van Puijenbroek: None declared, Naomi Jessurun: None declared

Background:Patient-reported outcomes (PROs) on adverse drug reactions (ADRs) are increasingly used in cohort event monitoring (CEM) to obtain a better understanding of patient’s real-world experience with drugs. Despite the leading role for patients, little is known about their perspectives on these monitoring systems.Objectives:To obtain more insight in patients’ perspectives on the perceived usefulness, ease of use and attitude toward using the Dutch Biologic Monitor (DBM), and their preferred design for a national drug safety monitoring system for immune-mediated inflammatory diseases (IMIDs).Methods:We developed a cross-sectional open survey following the rationale of the Technology Acceptance Model to obtain insight in patients’ perspectives on the DBM. The DBM is a pilot for a PRO-based drug safety monitoring system focused on ADRs attributed to biologics that are prescribed for IMIDs. This survey consisted of 20 categorical and 1 open-ended question. Seven categorical questions contained a text field for additional comments. Five-point Likert-type scales or multiple-choice questions were used to identify patients’ preferences and perspectives. Patients were eligible for the survey if they were still enrolled in the DBM at the time of the survey opening and if they had completed at least one questionnaire of the DBM. Categorical questions were descriptively analyzed, whereas text fields were analyzed using theoretical thematic analysis.Results:At the start of the survey a total of 1,225 patients had participated in the DBM. Approximately 70% had an inflammatory rheumatic disease. The survey was completed by 292 eligible respondents (response rate 44.8%). The respondents generally agreed that it was useful to participate in the DBM and would recommend it to their peers (Figure 1). The response burden of the bimonthly questionnaires was scored as ‘low’, irrespective of the presence of ADRs or education level (Table 1). A number of respondents suggested that the questionnaire frequency should be synchronized with the regular hospital visits or the administration schedule of the biologic. Moreover, questionnaires should be offered less frequent and preferably shortened in case of an unaltered situation or absence of ADRs. Half (49.0%) of the respondents was interested in sharing their questionnaires with a medical specialist, whereas a third (34.2%) advocated sharing the questionnaires with their pharmacist (Figure 1).Table 1.Perceived response burden of the Dutch Biologic Monitor questionnaires. The average burden is calculated using a five-point Likert-type scale. Data is represented as the number of respondents (n).Overall(n = 292)ADRs reportedEducation levelaYes(n = 225)No(n = 54)Do not know(n = 13)Lower(n = 149)Higher(n = 139)Burdenn(%)n(%)n(%)n(%)n(%)n(%)1: No burden224(76.7)169(75.1)46(85.2)9(69.2)106(71.1)115(82.7)2: Low burden58(19.9)48(21.3)7(13.0)3(23.1)36(24.2)22(15.8)3: Moderate burden6(2.1)6(2.7)0(0.0)0(0.0)4(2.7)2(1.4)4: High burden0(0.0)0(0.0)0(0.0)0(0.0)0(0.0)0(0.0)5: Very high burden0(0.0)0(0.0)0(0.0)0(0.0)0(0.0)0(0.0)No opinion4(1.4)2(0.9)1(1.9)1(0.0)3(2.0)0(0.0)Average burden1.21.31.11.21.31.2aMissing: 4 respondents.Figure 1.Stacked bar graph of user perspectives. Agreement scores were measured using a five-point Likert-type scale. The average agreement score per statement is indicated on the far right. The percentages represent the share of respondents. DBM: Dutch Biologic Monitor; ADRs: adverse drug reactions.Conclusion:This study provides valuable insights in the patient perspective on a PRO-based drug safety monitoring system for inflammatory rheumatic diseases and other IMIDs, and provides several useful starting points to further stimulate and improve PRO-based CEM systems. Altogether, it appears feasible to establish a PRO-based drug safety monitoring system that monitors IMID patients’ real-world experience with ADRs that has a low burden for the participants.Disclosure of Interests:Leanne Kosse: None declared, Gerda Weits: None declared, Harald Vonkeman Grant/research support from: AbbVie, Amgen, AstraZeneca, BMS, Celgene, Celltrion, Galapagos, Gilead, GSK, Janssen-Cilag, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi-Genzyme, all outside the submitted work., Sander Tas Grant/research support from: AbbVie, Arthrogen, AstraZeneca, BMS, Celgene, Galapagos, GSK, MSD, Pfizer, Roche, Sanofi-Genzyme, all outside the submitted work., Frank Hoentjen Speakers bureau: Abbvie, Janssen-Cilag, MSD, Takeda, Celltrion, Teva, Sandoz and Dr Falk, all outside the submitted work, Consultant of: Celgene, Janssen-Cilag, all outside the submitted work, Grant/research support from: Dr Falk, Janssen-Cilag, Abbvie, Takeda, all outside the submitted work, Martijn van Doorn Grant/research support from: Leopharma, Novartis, Abbvie, BMS, Celgene, Lilly, MSD, Pfizer, Sanofi-Genzyme, Janssen Cilag, outside the submitted work., Phyllis Spuls Grant/research support from: Departmental independent research grant for TREAT NL registry from different companies, is involved in performing clinical trials with many pharmaceutical industries that manufacture drugs used for the treatment of e.g. psoriasis and atopic dermatitis, for which financial compensation is paid to the department/hospital and, is Chief Investigator (CI) of the systemic and phototherapy atopic eczema registry (TREAT NL) for adults and children and one of the main investigators of the SECURE-AD registry, all outside the submitted work., Geert D’Haens Consultant of: Abbvie, Ablynx, Active Biotech AB, Agomab Therapeutics, Allergan, Alphabiomics, Amakem, Amgen, AM Pharma, Applied Molecular Therapeutics, Arena Pharmaceuticals, AstraZeneca, Avaxia, Biogen, Bristol Meiers Squibb/Celgene, Boehringer Ingelheim, Celltrion, Cosmo, DSM Pharma, Echo Pharmaceuticals, Eli Lilly, Engene, Exeliom Biosciences, Ferring, DrFALK Pharma, Galapagos, Genentech/Roche, Gilead, Glaxo Smith Kline, Gossamerbio, Pfizer, Immunic, Johnson and Johnson, Kintai Therapeutics, Lycera, Medimetrics, Takeda, Medtronic, Mitsubishi Pharma, Merck Sharp Dome, Mundipharma, Nextbiotics, Novonordisk, Otsuka, Photopill, ProciseDx, Prodigest, Prometheus laboratories/Nestle, Progenity, Protagonist, RedHill, Robarts Clinical Trials, Salix, Samsung Bioepis, Sandoz, Seres/Nestec/Nestle, Setpoint, Shire, Teva, Tigenix, Tillotts, Topivert, Versant and Vifor, all outside the submitted work, Michael Nurmohamed Speakers bureau: AbbVie, Celgene, Celltrion, Eli Lilly, Janssen, Sanofi, all outside the submitted work, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Roche, Sanofi, all outside the submitted work, Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, MSD, Mundipharma, Novartis, Pfizer, Roche, Sanofi, all outside the submitted work, Eugène van Puijenbroek: None declared, Bart van den Bemt: None declared, Naomi Jessurun: None declared

RESUMORealiza-se um questionamento acerca da legitimidade da decisão cometida pelo Supremo Tribunal Federal, resultante da divisão de competências entre os poderes da União. A metodologia utilizada foi a de investigação bibliográfica, tendo base nas críticas levantadas por Lênio Streck sobre a atuação do Poder Judiciário, caracterizando-a como um ativismo judicial a ser combatido, fazendo-se uma reflexão sobre as motivações concretas que fazem o ativismo vir a ocorrer, utilizando-se das considerações de Rachel Nigro, que propõe uma revisão dos conceitos de democracia, fazendo defesa de um ativismo legítimo e necessário. Sendo assim, reconhece-se as negativas do ativismo judicial, mas também se reconhece as negativas da não tutela dos direitos fundamentais em nome de uma aplicação restrita do texto constitucional. Isso, pois, deixar as famílias homoafetivas à margem daquilo que lhe é de Direito, esperando a boa vontade legislativa, vai contra ao que é, de fato, democrático e constitucional. Pontua-se, ainda, da carga simbólica que uma produção normativa coerente aos aspectos fáticos das famílias homoafetivas traria para efetivar a seguridade jurídica e social de tal grupo. PALAVRAS-CHAVE: Ativismo Judicial; Direitos Fundamentais; União Homoafetiva. ABSTRACTA questioning about the legitimacy of the decision made by the Federal Supreme Court, resulting from the division of competences between the powers of the Union, was carried out. The methodology used was that of bibliographic research, based on the criticisms raised by Lênio Streck about the performance of the Judiciary, characterizing it as a judicial activism to be fought, reflecting on the concrete motivations that make the activism come to take place, using the considerations of Rachel Nigro, who proposes a revision of the concepts of democracy, making defense of legitimate and necessary activism. thus, it acknowledges the negatives of judicial activism, but also acknowledges the denials of non-protection of Fundamental Rights in the name of a restricted application of the constitutional text. this, therefore, leaving homoaffective families to the margin of what is their right, waiting for legislative goodwill, goes against what is, in fact, democratic and constitutional. the symbolic burden that a coherent normative production of the factual aspects of homoaffective families would bring to the juridical and social security of such a group is also punctuated. KEYWORDS: Judicial Activism; Fundamental rights; Homoaffective Union.

In September 2010, celery plants with leaf cupping and petiole twisting were observed in commercial production fields located in Barry, Kent, Newago, and Van Buren Counties in Michigan. Long, elliptical lesions were observed on petioles but signs (mycelia, conidia, or acervuli) were not readily observed. Celery petioles were incubated in humid chambers (acrylic boxes with wet paper towels). After 24 h, conidia corresponding to the genus Colletotrichum were observed. Isolations were performed by excising pieces of celery tissue from the lesion margin and placing them on potato dextrose agar (PDA) amended with 30 ppm of rifampicin and 100 ppm of ampicillin. Plates were incubated at 21 ± 2°C under fluorescent light for 5 days. Fungal colony morphology was gray with salmon-colored masses of spores when viewed from above, and carmine when viewed from below. Isolates were single-spored and placed on 30% glycerol in –20°C, and cryoconservation media (20% glycerol, 0.04% yeast extract, 0.1% malt extract, 0.04% glucose, 0.02% K2HPO4) at –80°C. Conidia were 8.5 to 12.0 × 2.8 to 4.0 μm and straight fusiform in shape. Three isolates were confirmed as C. acutatum sensu lato based on sequences of the internal transcribed spacer (ITS) region of the nuclear ribosomal RNA and the 1-kb intron of the glutamine synthase gene (3), both with 100% similarity with Glomerella acutata sequences. Sequences were submitted to GenBank (Accession Nos. JQ951599 and JQ951600 for ITS and GS, respectively). Additionally, C. acutatum specific primer CaIntg was used in combination with the primer ITS4 on 54 isolates from symptomatic celery plants, obtaining the expected 490-pb fragment (1). Koch's postulates were completed by inoculating 4-week-old celery seedlings of cultivars Sabroso, Green Bay, and Dutchess using three plants per cultivar. Prior to inoculation, seedlings were incubated for 16 h in high relative humidity (≥95%) by enclosing the plants in humid chambers. Seven-day-old C. acutatum s. l. colonies were used to prepare the inoculum. Seedlings were spray-inoculated with a C. acutatum s. l. conidial suspension of 1 × 106 conidia/ml in double-distilled water plus Tween 0.01%. Two control seedlings per cultivar were sprayed with sterile, double-distilled water plus 0.01% Tween. Plants were enclosed in bags for 96 h post inoculation and incubated in a greenhouse at 27°C by day/20°C by night with a 16-h photoperiod. Leaf curling was observed on all inoculated plants of the three cultivars 4 days after inoculation (DAI). Petiole lesions were observed 14 to 21 DAI. Conidia were observed in lesions after incubation in high humidity at 21 ± 2°C for 24 to 72 h. Symptomatic tissue was excised and cultured onto PDA and resulted in C. acutatum colonies. Control plants remained symptomless. C. acutatum (4) and C. orbiculare (2) were reported to cause celery leaf curl in Australia in 1966 (2,4). To our knowledge, this is the first report of C. acutatum s. l. infecting celery in Michigan. References: (1) A. E. Brown et al. Phytopathology 86:523, 1996. (2) D. F. Farr and A. Y. Rossman. Fungal Databases. Syst. Mycol. Microbiol. Lab., USDA-ARS. Retrieved from http://nt.ars-grin.gov/fungaldatabases/ , 10 September 2010. (3) J. C. Guerber et al. Mycologia 95:872, 2003. (4) D. G. Wright and J. B. Heaton. Austral. Plant Pathol. 20:155, 1991.

Background: A myeloproliferative neoplasm (MPN) is frequent underlying cause of splanchnic vein thrombosis (SVT). We reported that ruxolitinib, a JAK1/2 inhibitor, was safe in patients (pts) with MPN-associated SVT and effective in reducing spleen size at the planned primary analysis at 24 weeks (w) in an investigator-initiated phase II clinical trial (Pieri L, AJH 2016). Herein we present final long term follow up (FU) data. Methods. A total of 21 MPN-SVT entered the trial in 2012. Pts who completed the 24w core study and well tolerated the drug and had evidence of clinically-significant improvement were allowed to enter an extension phase up to w72, then entered a long term FU. The drug was provided by Novartis, that had no role in trial design nor in data analysis. Safety data were reported as cumulative incidence of adverse events (CTCAE v4.03). Clinical responses were defined according to ELN and IWG-MRT criteria. Results. Patients disposition. Eighteen patients were alive at last follow-up at a median of 5.5y, range 3.7-6.5y. Two pts died before w72 (hepatocarcinoma; unknown cause), 1 pt died at w252 (sepsis). Diagnosis of the 18 pts was: PMF 8 (44%), PV 5 (28%), ET 4 (22%), PET-MF 1 (6%). The DIPSS risk score of the 8 pts with PMF was low in 4 and intermediate-1 in 4. At last FU, 14 patients are still on ruxolitinib (78%), 10 pts still on clinical trial, 4 pts shifted to commercial drug. Four pts (22%) withdrawn treatment after w72 because of inefficacy, withdrawal of consent, unknown reasons, shift to observation only (1 each). Safety. Thirteen pts (72.2%) had adverse events; the median number of events per patient was 5 (range, 0-37). Five pts had G2 thrombocytopenia plus 1 pt G3 (28%), 9 had G2 anemia (50%), 1 had G2 neutropenia (6%). There were 4 non-hematologic G3 adverse events (22%), one drug-related (CPK increase) that resolved with dose reduction. Six pts developed G1-2 infections (33%), 4 had Herpes Zoster reactivation (22%), 1 developed second cancer (pheochromocytoma at w96; 6%). Efficacy. Spleen response (defined as percentage reduction of spleen length from left costal margin (LCM) from baseline value as by IWG-MRT criteria) was available in 16 of 18 pts on treatment. Of 8 pts who obtained spleen response at w72, 4 pts had a complete response, while the remaining 4 pts had a spleen reduction >50%. At last FU, 6 of 8 pts (75%) adjudicated as spleen responders at w72 maintained the response. None of the 8 pts who had not obtained a spleen response at w72 acquired it at the last FU. According to ELN/IWG-MRT criteria of disease response, 7 pts had partial response, 11 had stable disease. At abdominal vessel eco scan, thrombosis improved in 3 of 12 evaluated pts (25%) and remained stable in the remaining 9. Of the 16 pts with endoscopic evaluation at last FU, complete resolution of oesophageal varices was documented in 3/12 with baseline varices (25%), worsening in 4 (33%), stable in 5 (42%), while no de-novo formation of F1 varices was documented in the remaining 4 (33%). No pt had gastrointestinal bleeding episodes. Exploratory endpoints. Included changes in the level of JAK2V617F variant allele burden (VAF) at last FU, available in 13 of 15 JAK2V617F mutated pts. VAF remained stable in 2 pts (13%), increased by 34% (range 25-40) in 3 pts, while 8 pts (62%) had a reduction >10% (range 18-96), of whom 6 (46%) had a reduction >50% (median 82%, range 70-96). By correlative analysis of JAK2 VAF changes and spleen response, 3 of 6 pts with VAF reduction of >50% had complete spleen response, as compared to none of the 3 pts who had an increase of VAF. Conclusions. After a median follow-up of 5.5 years, ruxolitinib continues to be safe in pts with MPN-associated SVT and maintains efficacy against splenomegaly in 33% of the pts. Of note, the large majority of pts (67%) showed stabilization or improvement of oesophageal varices, supporting the hypothesis that sustained reduction of enlarged spleen might contribute to decrease the upstream venous system pressure. Significant reduction of JAK2V617F VAF>50% was documented in 40% of the pts, although it was not clearly correlated with clinical improvement. Disclosures Rumi: novartis: Honoraria, Research Funding. Vannucchi:Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees; Incyte: Membership on an entity's Board of Directors or advisory committees; Italfarmaco: Membership on an entity's Board of Directors or advisory committees; CTI BioPharma: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. OffLabel Disclosure: Ruxolitinib use in essential thrombocythemia

Objective: Levels of insulin-like growth factor 1 (IGF-1) have been associated with prostate carcinoma. We have investigated whether IGF-1 level has an early predictive value for the biochemical relapse in the prostate carcinoma patients with a negative surgical margin who underwent curative surgery. Materials and Methods: We retrospectively analyzed 82 patients who were followed-up regularly and did not receive neoadjuvant or adjuvant chemotherapy. We classified patients as having Gleason scores ≥7 and <7, PSA values ≥10 ng/ml and <10, biochemical relapse positive or negative, T stages ≥T2 and <T2, tumor burden in less or more than 50% pathologic specimens, respectively. PSA cut-off value accepted was as 0.2 ng/ml. According to average values in the literature, time to PSA relapses was considered early if it was less than 18 months and late if more than 18 months. We measured PSA and IGF-1 levels at each routine control visit. Results: During 60-month follow-up, 66 (80.4%) patients had no relapse, while in 8 (9.8%) patients had early, and other 8 (9.8%) patients had a late biochemical relapse. There was no statistically significant difference between these 3 groups of patients according to their age, tPSA levels, and BMI parameters. We compared IGF-1 levels with tumor burden, tPSA levels, tumor grade, and Gleason scores without any significant difference between these parameters. When we accepted IGF-1 cut-off values as 60 ng/ml, we observed higher Gleason scores (≥ 7 and more) in these patients. There was a weak relationship between IGF-1 levels of non-relapse and early relapse patients (p:0.078). However, when we evaluated IGF-1 levels among patients with relapse, the early relapse group had significantly higher IGF-1 levels (p: 0.006). When the cut-off value of IGF-1 was accepted as 60 ng/ml, which was found to be significant for Gleason score, the early relapse group had significantly higher IGF-1 levels compared to the non-relapse group (p:0.023). Conclusions: According to our study, the IGF-1 level has a predictive value for showing biochemical recurrence after surgery. Nevertheless, considering the number of patients, we need randomized controlled trials with a large number of patients.

ObjectiveTo assess the level of circulation of DENV, CHIKV, ZIKV, MAYV in French Guiana.IntroductionArboviral infections have become a significant public health problem with the emergence and re-emergence of arboviral diseases worldwide in recent decades [1-6]. Given the increasing number of cases, geographic spread, but also health, social and economic impact of arboviral outbreaks, estimating their true burden represents a crucial issue but remains a difficult task [7-10].In French Guiana, the epidemiology of arboviral diseases has been marked by the occurrence several major dengue fever (DENV) outbreaks over the past few decades, recent emergences of Chikungunya (CHKV) and Zika virus (ZIKV) and the circulation of Mayaro virus (MAYV) [11-14].MethodsTo assess antibody seroprevalence against DENV, CHIKV, ZIKV, MAYV a random 2-stage household cross-sectional survey was conducted among the general population. We enrolled 2,697 individuals aged 1-87 years from June 1 to 12 October 2017. We performed detection of DENV, CHIKV, ZIKV, MAYV IgG antibodies on collected blood samples using a microsphere immunoassay (MIA). Socio-economic data, environmental variables and exposure to mosquitoes, perceptions of the illness and risk of contracting arboviral infections were collected using a standardized questionnaire administrated to all individuals included in the survey. Cross-reactivity between same families of viruses was taking into account using seroneutralisation and modeling approaches.ResultsOverall seroprevalence rates for antibodes against DENV were 69.5% [66.4%-72.5%] and differed significantly according to age and geographical area. Seroprevalence rates of CHIKV, ZIKV and MAYV antibodies were respectively 19.3% [16.5%-22.5%], 23.1% [19.5%-27.2%] and 9.6% [8.1%-11.3%] and did not differed significantly according to gender or age.The distribution of seroprevalence rates for CHIKV, ZIKV antibodies differed from extrapolations obtained from routine surveillance systems and brings valuable information to assess the epidemic risk of future outbreaks. MAYV has been circulating in the southern part of FG, at levels that appear to be substantially higher than those estimated from epidemiological and virological surveillance.ConclusionsSerological surveys provide the most direct measurement for defining the immunity landscape for infectious diseases, but the methodology remains difficult to implement particularly in the context of high cross-reactivity between flaviviruses or alphaviruses [15]. The development of reliable, rapid and affordable diagnosis tools and the use of innovative modeling approaches represent a significant issue concerning the ability of seroprevalence surveys to differentiate infections when multiple viruses co-circulate.References1. 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. pmid:235632662. Stanaway JD, Shepard DS, Undurraga EA, Halasa YA, Coffeng LE, Brady OJ, et al. The global burden of dengue: an analysis from the Global Burden of Disease Study 2013. Lancet Infect Dis. 2016;16: 712–723. pmid:268746193. Brathwaite Dick O, San Martín JL, Montoya RH, del Diego J, Zambrano B, Dayan GH. The history of dengue outbreaks in the Americas. Am J Trop Med Hyg. 2012;87: 584–593. pmid:230428464. Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika Virus. N Engl J Med. 2016;374: 1552–1563. pmid:270285615. Staples JE, Breiman RF, Powers AM. Chikungunya fever: an epidemiological review of a re-emerging infectious disease. Clin Infect Dis Off Publ Infect Dis Soc Am. 2009;49: 942–948. pmid:196636046. Duffy MR, Chen T-H, Hancock WT, Powers AM, Kool JL, Lanciotti RS, et al. Zika Virus Outbreak on Yap Island, Federated States of Micronesia. N Engl J Med. 2009;360: 2536–2543. pmid:195160347. Donoso Mantke O, Lemmer K, Biel SS, Groen J, Schmitz H, Durand JP, et al. Quality control assessment for the serological diagnosis of dengue virus infections. J Clin Virol. 2004;29: 105–112. pmid:147470298. Noden BH, Musuuo M, Aku-Akai L, van der Colf B, Chipare I, Wilkinson R. Risk assessment of flavivirus transmission in Namibia. Acta Trop. 2014;137: 123–129. pmid:248657929. Martins AC, Pereira TM, Oliart-Guzmán H, Delfino BM, Mantovani SAS, et al. Seroprevalence and Seroconversion of Dengue and Implications for Clinical Diagnosis in Amazonian Children, Seroprevalence and Seroconversion of Dengue and Implications for Clinical Diagnosis in Amazonian Children. Interdiscip Perspect Infect Dis Interdiscip Perspect Infect Dis. 2014;2014: e703875. pmid:2554855810. Conlan JV, Vongxay K, Khamlome B, Jarman RG, Gibbons RV, Fenwick SG, et al. Patterns of Flavivirus Seroprevalence in the Human Population of Northern Laos. Am J Trop Med Hyg. 2015;93: 1010–1013. pmid:2630492511. Flamand C, Quenel P, Ardillon V, Carvalho L, Bringay S, Teisseire M. The epidemiologic surveillance of dengue-fever in French Guiana: when achievements trigger higher goals. Stud Health Technol Inform. 2011;169: 629–633. pmid:2189382412. Adde A, Roucou P, Mangeas M, Ardillon V, Desenclos J-C, Rousset D, et al. Predicting Dengue Fever Outbreaks in French Guiana Using Climate Indicators. PLOS Negl Trop Dis. 2016;10: e0004681. pmid:2712831213. Fritzell C, Raude J, Adde A, Dusfour I, Quenel P, Flamand C. Knowledge, Attitude and Practices of Vector-Borne Disease Prevention during the Emergence of a New Arbovirus: Implications for the Control of Chikungunya Virus in French Guiana. PLOS Negl Trop Dis. 2016;10: e0005081. pmid:2780227514. Flamand C, Fritzell C, Matheus S, Dueymes M, Carles G, Favre A, et al. The proportion of asymptomatic infections and spectrum of disease among pregnant women infected by Zika virus: systematic monitoring in French Guiana, 2016. Eurosurveillance. 2017;22.15. Fritzell C, Rousset D, Adde A, Kazanji M, Van Kerkhove MD, Flamand C (2018) Current challenges and implications for dengue, chikungunya and Zika seroprevalence studies worldwide: A scoping review. PLoS Negl Trop Dis 12(7): e0006533.

Dream, 2008Go to visit a friend with vulvodynia who recently had a baby only to find that she is desolate. I realise the baby–a little boy–died. We go for a walk together. She has lost weight through the ordeal & actually looks on the edge of beauty for the first time. I feel like saying something to this effect–like she had a great loss but gained beauty as a result–but don’t think it would be appreciated. I know I shouldn’t stay too long &, sure enough, when we get back to hers, she indicates she needs for me to go soon. In her grief though, her body begins to spasm uncontrollably, describing the arc of the nineteenth-century hysteric. I start to gently massage her back & it brings her great relief as her body relaxes. I notice as I massage her, that she has beautiful gold and silver studs, flowers, filigree on different parts of her back. It describes a scene of immense beauty. I comment on it.In 2008, I was following a writing path dictated by my vulvodynia, or chronic vulval pain, and was exploring the possibility of my disorder being founded in trauma. The theory did not, in my case, hold up and I had decided to move on when serendipity intervened. Books ordered for different purposes arrived simultaneously and, as I dipped into the texts, I found startling correspondence between them. The books? Neurologist Jean-Martin Charcot’s lectures on hysteria, translated into English in 1889; psychiatrist W.H.R. Rivers’s explication of a biological theory of the neuroses published in 1922; and trauma neurologist Robert C. Scaer’s interpretation, in 2007, of the psychosomatic symptoms of his patients. The research grasped my intellect and imagination and maintained its grip until the ensuing chapter was done with me: my day life, papers and books skewed across tables; my night life, dreams surfeited with suffering and beauty, as I struggled with the possibility of any relationship between the two. Just as Rivers recognised that the shell-shock of World War I was not a physical injury as such but a trigger for and form of hysteria, so too, a few decades earlier, did Charcot insistently equate the railway brain/spine that resulted from railway accidents, with the hysteria of other of his patients, recognising that the precipitating incident constituted trauma that lodged in the body/mind of the victim (Clinical 221). More recently, Scaer notes that the motor vehicle accident (MVA) from which whiplash ensues is usually of insufficient force to logically cause bodily injury and, through this understanding, links whiplash and the railway brain/spine of the nineteenth century (25).In terms of comparative studies, most exciting for a researcher is the detail with which Charcot described patient after patient with hysteria in the Salpêtrière hospital, and elements of correspondence in symptomatology between these and Scaer’s patients, the case histories of which open most chapters of his book, titled appropriately, The Body Bears the Burden.Here are symptoms selected from a case study from each clinician:She subsequently developed headaches, neck pain, panic attacks, and full-blown post-traumatic stress disorder, along with significant cognitive problems [...] As her neck pain worsened and spread to her lower back, shoulders and arms, she noted increasing morning stiffness, and generalized pain and sensitivity to touch. With the development of interrupted, non-restorative sleep and chronic fatigue, she was ultimately diagnosed by a rheumatologist with fibromyalgia (Scaer 107).And:The patient suffers from a permanent headache of a constrictive character [...] All kinds of sound are painful to his ear, and he does his best to avoid them. It is impossible for him to fix his attention to any matter, or to devote himself to anything without speedily experiencing very great fatigue [...] He has insomnia and is frequently tormented by horrible dreams [...] Further, his memory appears to be considerably weakened (Charcot, Clinical 387).In the case of both patients, there was no significant physical injury, though both were left physically, as well as psychically, disabled. In the accidents that precipitated these symptoms, both were placed in positions of terrified helplessness as potential destruction bore down on them. In the case of Scaer’s patient, she froze in the driver’s seat at traffic lights as a large dump truck slowly reversed back on to her car, crushing the bonnet and engine compartment as it moved inexorably toward her. In the case of Charcot’s patient, he was dragging his barrow along the road when a laundryman’s van, pulled at “railway speed” by a careering horse, bore down on him, striking the wheel of his barrow (Clinical 375). It took some hours for the traumatised individuals of each incident to return to their senses.Scaer describes whiplash syndrome as “a diverse constellation of symptoms consisting of pain, neurologic symptoms, cognitive impairment, and emotional complaints” (xvii), and argues that the somatic or bodily expressions of the syndrome “may represent a universal constellation of symptoms attributable to any unresolved life-threatening experience” (143). Thus, as we look back through history, whiplash equals shell-shock equals railway brain equals the “swooning” and “vapours” of the eighteenth century (Shorter Chap. 1). All are precipitated by different causes, but all share the same outcome; diverse, debilitating symptoms affecting the body and mind, which have no reasonable physical explanation and which show no obvious organic cause. Human stress and trauma have always existed.In modern and historic studies of hysteria, much is made of the way in which the symptoms of hysterics have, over the centuries, mimicked “real” organic conditions (e.g. Shorter). Rivers discusses mimesis as a quality of the “gregarious” or herd instinct, noting that the enhanced suggestibility of such a state was utilised in military training. Here, preparation for combat focused on an unthinking obedience to duty and orders, and a loss of individual agency within the group: “The most successful training is one which attains such perfection of this responsiveness that each individual soldier not merely reacts at once to the expressed command of his superior, but is able to divine the nature of a command before it is given and acts as a member of the group immediately and effectively” (211–12). In the animal kingdom, the herd instinct manifests in behaviour that impacts the survival of prey and predator: schools of sardines move as one organism, seeking safety in numbers, while predatory sailfish act in silent concert to push the school into a tighter formation from which they can take orchestrated turns to feed.Unfortunately, the group mimesis created through a passive surrender of the individual ego to the herd, while providing a greater sense of security and chance of survival, also made World War I soldiers more vulnerable to the development of post-traumatic hysteria. At the Salpêtrière, Charcot described in meticulous detail the epileptic-like convulsions of hysteria major (la grande hystérie), which appeared to be an unwitting imitation of the seizures of epileptic inmates with whom hysteria patients were housed. Such convulsions included the infamous arc en circle, or backward-arched bodily semicircle, through which the individual’s body was thrust, up into the air, in an arc of distress only earthed by flexed feet and contorted neck (Veith 231). The suffering articulated in this powerful image stayed with me as I read, and percolated through my dreams.The three texts in which I remained transfixed had issued from different eras and used different language from each other, but all three contained similar and complementary insights. I found further correspondence between Charcot and Scaer in their understanding of the neurophysiology underlying hysteria/trauma. Though he did not have the technology to observe it, Charcot insisted that the symptoms of hysteria were the result of real changes in the nervous system. He distinguished between “organic” causes of disease, and the “functional” or “dynamic” causes of such disorders as hysteria and epilepsy: as he noted of the “hystero-traumatic paraplegia” of a patient, “it depends upon a dynamic lesion affecting the motor and sensory zones of the grey cortex of the brain which in a normal state preside over the functions of that limb” (Clinical 382). He proposed a potentially reversible “dynamic alteration” in the brain of the hysteric (Clinical 223–24). Compare Scaer: “Clinical syndromes previously categorized as ‘nonphysiological,’ ‘psychosomatic,’ or ‘functional’ may be based on demonstrable dynamic neurophysiological changes in the brain” (xx–xxi).Another link between the work of Charcot and Scaer is their insistence on the mind/body as a continuum, rather than separate entities. The perspicacity of the two researcher/clinicians forms bookends to a model separating mind from body that, in the wake of the popularisation and distortion of Freudian theory, characterised the twentieth-century. Said Charcot: “the physician must be a psychologist if he wants to interpret the most refined of cerebral functions, since psychology is nothing else but physiology of a part of the brain” (cited by Goetz 32). Says Scaer: “The distinction between the ‘psychological’ and physical pathological manifestations of traumatic stress, as suggested in the term ‘psychosomatic,’ needs to be discarded” (127). He proposes that, instead, we consider a mind/brain/body continuum which more accurately reflects, “the pathophysiological, neurobiological, endocrinological, and immunological changes induced by trauma” and the bodily manifestations of disease which follow (127).Charcot’s modernity is perhaps most evident in his understanding of equivalence between mind and brain, and his belief in what we now call “neuroplasticity”. Dealing with two patients with hysterical (traumatic) paralysis, Charcot recognised the value of friction, massage, and passive movements of the paralysed limb, not to build muscle strength, but to “revive” the “motor representation” in the brain as a necessary precursor to voluntary movement (Clinical 310). He noted the way in which, through repetition, movement strengthens. The parallel between Charcot’s insight, and recent research and practice which indicates that intense exercise for stroke victims assists the retrieval of motor programmes in the nervous system, in turn facilitating increased strength and movement, is quite astounding (Doidge Chap. 5).Scaer, like Rivers before him, understands the “freeze” or immobility response to threat as a very primitive or arcane level of the survival instinct. When neither fight nor flight will ensure an animal’s survival, it often manifests the freeze response, playing “dead”. After danger has passed, the animal might vibrate and shake, discharging the stored energy, physiologically “effecting” its defence or escape, and becoming fully functional again. Scaer describes this discharge process in animals as being “as imperceptible as a shudder, or as dramatic as a grand mal seizure” (19). The human, being an animal, also instinctually resorts to immobility when that is the reaction that will best ensure survival. As a result of this response, energy that would have been discharged in fighting or fleeing is bound up in the nervous system, along with accompanying terror, rage and helplessness. Unlike other animals that naturally discharge this energy when safe, humans often cognitively override the subtle but essential restorative behaviours that complete the full instinctual response, leaving them in a vicious cycle of fear and immobility and ultimately generating the symptoms of trauma.Scaer writes, “this apparent lack of discharge of autonomic energy after the occurrence of freezing [...] may represent a dangerous suppression of instinctual behavior, resulting in the imprinting of the traumatic experience in unconscious memory and arousal systems of the brain” (21). He proposes a persuasive model of “somatic dissociation” in which the body continues to manifest a threat to survival through impairment of the region of the body that perceived the sensory messages, and disability that reflects the incomplete motor defence (100). He writes of his patients in a chronic pain programme: “We invariably noticed that the patient’s unconscious posture reflected not only the pain, but also the experience of the traumatic event that produced the pain. The asymmetrical postural patterns, held in procedural memory, almost always reflect the body’s attempt to move away from the injury or threat that caused the injury” (84).Scaer’s concept of somatic dissociation, when applied to some of Charcot’s case studies, makes sense of their bodily symptoms. Charcot’s patient P— experiences no life threat, but a shock that involves grief and shame (Clinical 131–39). On a fox-hunting outing, he mistakes his friend’s dog for a fox, accidently shooting it dead. The friend is distraught, and P— consequently deeply distressed. He continues with the hunt, but later, when he raises his fire-arm to shoot a rabbit, collapses with a paralysis of the right side (he is right-handed), and then a loss of consciousness, with consequent confused recollection. Charcot’s lecture focuses on the “word-blindness” P— evidences, apparently associated with post-traumatic memory-deficits, but what is also arresting is the right-sided paralysis which lasts for some days, and the loss of vision on his right side. It is as if the act to shoot again is prevented by a body, shocked by its former action. The body parts affected hold meaning.In the case of the barrow man discussed earlier; although he has no lasting organic damage to his legs, nevertheless, his “feet remain literally fixed to the ground” (Clinical 378) when he is standing, perhaps reproducing the immobility with which he faced the rapidly looming van as it bore down on him. His paralysis speaks of his frozen helplessness, the trauma now locked in his body.In the case of the patient Ler—, aged around sixty, Charcot links her symptoms with a “series of frights” (Lectures 279): at eleven she was terrorised by a mad dog; at sixteen she was horrified by the sight of the corpse of a murdered woman; and, at the same age, she was threatened by robbers in a wood. During her violent hystero-epileptic attacks Ler— “hurls furious invectives against imaginary individuals, crying out, ‘villains! robbers! brigands! fire! fire! O, the dogs! I’m bitten!’” (Lectures 281). Here, the compilation of trauma is articulated through the body and the voice. Given that the extreme early childhood poverty and deprivation of Ler— were typical of hysterical patients at the Salpêtrière (Goetz 193), one might speculate that the hospital population of hysterics was composed of often severely traumatised women.The traumatised person is left with a constellation of symptoms familiar to anyone who has studied the history of hysteria. These comprise, but are not limited to, flashbacks, panic attacks, insomnia, depression, and unprovoked rage. The individual is also affected by physical symptoms that might include blindness or mutism, paralysis, spasms, skin anaesthesia, chronic fatigue, irritable bowel, migraines, or chronic pain. For trauma theorist Peter A. Levine, the key to healing lies in completing the original instinctual response; “trauma is part of a natural physiological process that simply has not been allowed to be completed” (155). The traumatised person stays stuck in or compulsively relives trauma in order to do just that. In 1885, Jean-Martin Charcot lectured at the Salpêtrière hospital in Paris, including among his case studies the patient he names Deb—. She resides more evocatively in my imagination as “the lady in the carriage”, a title drawn from Charcot’s description of her symptoms, and from the associated photographs which capture static moments of her frenzied and compulsive dance:Now look at this patient [...] In the first phase, rhythmical jerkings of the right arm, like the movements of hammering, occur [...] Then after this period there succeeds a period of tonic spasms, and of contortions of the arm and head, recalling partial epilepsy [...] Finally, measured movements of the head to the right and the left occur; rapid movements defying all interpretation, for I ask you, what do they correspond to in the region of physiological acts? At the same time the patient utters a cry, or rather a kind of plaintive wail, always the same [...] You see by this example that rhythmical chorea may be in certain cases a grave affection [affliction]. Not that it directly menaces life, but that it may persist over a very long period of time, and become a most distressing infirmity [...] The chorea has lasted for more than thirty years [...] The onset occurred at the age of thirty-six. About this time, when out driving in a carriage with her husband, she fell over a precipice with the horse and carriage. After the great fright which she had thus experienced she lost consciousness for three hours. This was followed by a convulsive seizure of hysteria major, by rigidity of the limbs of the right side, and cries like the barking of a dog (Clinical 193–95).I found this case study early in my reading of Charcot, but the lady in the carriage stayed with me as a trope of the relentless embodiment of trauma in its drive to be conclusively expressed, properly acknowledged, and potentially understood. Hence the persistent pain and distress of Scaer’s MVA patients; the patients treated by Rivers, with limbs and vocal-chords frozen in a never-ending moment of self-defence; the dramatic hysterical attacks of the impoverished patients in Charcot’s Salpêtrière; and the rhythmical chorea of the lady in the carriage, her involuntary jerky dance a physical re-enactment of her original trauma, when the carriage in which she was driving went over a precipice. Her helplessness in the event which precipitated her hysteria is a central factor in her continuing distress, her involuntary passivity removing her sense of agency and, like the soldier confined endlessly and powerlessly in the trenches waiting for inevitable terrifying action, rendering her unable to fight or flee.The fact that the lady in the carriage may be stuck in a traumatic incident experienced more than thirty years before attests to the way in which trauma insistently pushes to be resolved. Her re-enactment is literal, but Levine acknowledges the relevance of a “repetition compulsion” (181), expressed originally by Freud as the “compulsion to repeat” (19). This describes the often subtle way in which we continue to involve ourselves in situations that are replays of traumatic themes from childhood—symbolic re-enactments. Levine revitalises the idea however, by focusing on the interrupted instinctual response that calls for physiological resolution: “the drive to complete the freezing response remains active no matter how long it has been in place” (111).The knowledge a traumatised person seeks is, in trauma, literally locked in the body/mind. It rises up through dreams and throws itself aggressively at one in memories that are experienced as a terrifying present. It twists limbs in painful contractures and paralyzes the limb that was lifted in defence. The fear of turning to face this knowledge locks the individual in a recurring cycle of terror and immobility. At its end-point, s/he survives in the pathological limbo of Post-Traumatic Stress Disorder (PTSD), avoiding any arousal that might trigger all the physiological and emotional events of the original trauma. The original threat or trauma continues to exist in a perpetual present, with the individual unable to relegate it to the past as a bearable memory.It is possible to interpret such suffering in many ways. One might, for instance, focus on the pathology of an apparent system malfunction, which keeps the body/mind inefficiently glued to an unsolvable past. I choose to emphasise here, however, the creativity and persistence of the human body/mind in its drive to resolve the response to trauma, recover equilibrium and face effectively the recurrent challenges of life. As well as physical symptoms which exact attention, this drive or instinct might include the prompting of dreams and the meaningful coincidences we notice as we open our eyes to them, all of which can lead us down previously unconsidered paths. Does the body/mind only continue to malfunction due to our inability to correctly decipher its language? In relation to trauma, the body/mind bears the burden, but it might also hold the key to recovery.References Charcot, Jean-Martin. Lectures on the Diseases of the Nervous System. Trans. George Sigerson. London: The New Sydenham Society, 1877.---. Clinical Lectures on Diseases of the Nervous System: Volume 3. Trans. Thomas Savill. London: The New Sydenham Society, 1889.Doidge, Norman. The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science. Melbourne: Scribe, 2008.Freud, Sigmund. “Beyond the Pleasure Principle.” The Standard Edition of the Complete Psychological Works of Sigmund Freud. Ed. and Trans. James Strachey. London: Hogarth Press, 1955. 7–64.Goetz, Christopher G, Michel Bonduelle, and Toby Gelfand. Charcot: Constructing Neurology. New York: Oxford University Press, 1995.Levine, Peter A. Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, CA: North Atlantic Books, 1997.Rivers, W. H. R. Instinct and the Unconscious: A Contribution to a Biological Theory of the Psycho-Neuroses. 2nd ed. Cambridge: Cambridge University Press, 1922.Scaer, Robert C. The Body Bears the Burden: Trauma, Dissociation, and Disease. 2nd ed. New York: Haworth Press, 2007.Shorter, Edward. From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era. New York: Free Press, 1992.Veith, Ilza. Hysteria: The History of a Disease. Chicago: University of Chicago Press, 1965.

IntroductionTasmania hangs from the map of Australia like a drop in freefall from the substance of the mainland. Often the whole state is mislaid from Australian maps and logos (Reddit). Tasmania has, at least since federation, been considered peripheral—a region seen as isolated, a ‘problem’ economically, politically, and culturally. However, Tasmania not only cleaves to the ‘north island’ of Australia but is also subject to the gravitational pull of an even greater land mass—Antarctica. In this article, we upturn the political conventions of map-making that place both Antarctica and Tasmania in obscure positions at the base of the globe. We show how a changing global climate re-frames Antarctica and the Southern Ocean as key drivers of worldwide environmental shifts. The liquid and solid water between Tasmania and Antarctica is revealed not as a homogenous barrier, but as a dynamic and relational medium linking the Tasmanian archipelago with Antarctica. When Antarctica becomes the focus, the script is flipped: Tasmania is no longer on the edge, but core to a network of gateways into the southern land. The state’s capital of Hobart can from this perspective be understood as an “Antarctic city”, central to the geopolitics, economy, and culture of the frozen continent (Salazar et al.). Viewed from the south, we argue, Tasmania is not a problem, but an opportunity for a form of ecological, cultural, economic, and political sustainability that opens up the southern continent to science, discovery, and imagination.A Centre at the End of the Earth? Tasmania as ParadoxThe islands of Tasmania owe their existence to climate change: a period of warming at the end of the last ice age melted the vast sheets of ice covering the polar regions, causing sea levels to rise by more than one hundred metres (Tasmanian Climate Change Office 8). Eleven thousand years ago, Aboriginal people would have witnessed the rise of what is now called Bass Strait, turning what had been a peninsula into an archipelago, with the large island of Tasmania at its heart. The heterogeneous practices and narratives of Tasmanian regional identity have been shaped by the geography of these islands, and their connection to the Southern Ocean and Antarctica. Regions, understood as “centres of collective consciousness and sociospatial identities” (Paasi 241) are constantly reproduced and reimagined through place-based social practices and communications over time. As we will show, diverse and contradictory narratives of Tasmanian regionality often co-exist, interacting in complex and sometimes complementary ways. Ecocritical literary scholar C.A. Cranston considers duality to be embedded in the textual construction of Tasmania, writing “it was hell, it was heaven, it was penal, it was paradise” (29). Tasmania is multiply polarised: it is both isolated and connected; close and far away; rich in resources and poor in capital; the socially conservative birthplace of radical green politics (Hay 60). The weather, as if sensing the fine balance of these paradoxes, blows hot and cold at a moment’s notice.Tasmania has wielded extraordinary political influence at times in its history—notably during the settlement of Melbourne in 1835 (Boyce), and during protests against damming the Franklin River in the early 1980s (Mercer). However, twentieth-century historical and political narratives of Tasmania portray the Bass Strait as a barrier, isolating Tasmanians from the mainland (Harwood 61). Sir Bede Callaghan, who headed one of a long line of federal government inquiries into “the Tasmanian problem” (Harwood 106), was clear that Tasmania was a victim of its own geography:the major disability facing the people of Tasmania (although some residents may consider it an advantage) is that Tasmania is an island. Separation from the mainland adversely affects the economy of the State and the general welfare of the people in many ways. (Callaghan 3)This perspective may stem from the fact that Tasmania has maintained the lowest Gross Domestic Product per capita of all states since federation (Bureau of Infrastructure Transport and Regional Economics 9). Socially, economically, and culturally, Tasmania consistently ranks among the worst regions of Australia. Statistical comparisons with other parts of Australia reveal the population’s high unemployment, low wages, poor educational outcomes, and bad health (West 31). The state’s remoteness and isolation from the mainland states and its reliance on federal income have contributed to the whole of Tasmania, including Hobart, being classified as ‘regional’ by the Australian government, in an attempt to promote immigration and economic growth (Department of Infrastructure and Regional Development 1). Tasmania is indeed both regional and remote. However, in this article we argue that, while regionality may be cast as a disadvantage, the island’s remote location is also an asset, particularly when viewed from a far southern perspective (Image 1).Image 1: Antarctica (Orthographic Projection). Image Credit: Wikimedia Commons, Modified Shading of Tasmania and Addition of Captions by H. Nielsen.Connecting Oceans/Collapsing DistanceTasmania and Antarctica have been closely linked in the past—the future archipelago formed a land bridge between Antarctica and northern land masses until the opening of the Tasman Seaway some 32 million years ago (Barker et al.). The far south was tangible to the Indigenous people of the island in the weather blowing in from the Southern Ocean, while the southern lights, or “nuyina”, formed a visible connection (Australia’s new icebreaker vessel is named RSV Nuyina in recognition of these links). In the contemporary Australian imagination, Tasmania tends to be defined by its marine boundaries, the sea around the islands represented as flat, empty space against which to highlight the topography of its landscape and the isolation of its position (Davies et al.). A more relational geographic perspective illuminates the “power of cross-currents and connections” (Stratford et al. 273) across these seascapes. The sea country of Tasmania is multiple and heterogeneous: the rough, shallow waters of the island-scattered Bass Strait flow into the Tasman Sea, where the continental shelf descends toward an abyssal plain studded with volcanic seamounts. To the south, the Southern Ocean provides nutrient-rich upwellings that attract fish and cetacean populations. Tasmania’s coast is a dynamic, liminal space, moving and changing in response to the global currents that are driven by the shifting, calving and melting ice shelves and sheets in Antarctica.Oceans have long been a medium of connection between Tasmania and Antarctica. In the early colonial period, when the seas were the major thoroughfares of the world and inland travel was treacherous and slow, Tasmania’s connection with the Southern Ocean made it a valuable hub for exploration and exploitation of the south. Between 1642 and 1900, early European explorers were followed by British penal colonists, convicts, sealers, and whalers (Kriwoken and Williamson 93). Tasmania was well known to polar explorers, with expeditions led by Jules Dumont d’Urville, James Clark Ross, Roald Amundsen, and Douglas Mawson all transiting through the port of Hobart. Now that the city is no longer a whaling hub, growing populations of cetaceans continue to migrate past the islands on their annual journeys from the tropics, across the Sub-Antarctic Front and Antarctic circumpolar current, and into the south polar region, while southern species such as leopard seals are occasionally seen around Tasmania (Tasmania Parks and Wildlife). Although the water surrounding Tasmania and Antarctica is at times homogenised as a ‘barrier’, rendering these places isolated, the bodies of water that surround both are in fact permeable, and regularly crossed by both humans and marine species. The waters are diverse in their physical characteristics, underlying topography, sea life, and relationships, and serve to connect many different ocean regions, ecosystems, and weather patterns.Views from the Far SouthWhen considered in terms of its relative proximity to Antarctic, rather than its distance from Australia’s political and economic centres, Tasmania’s identity undergoes a significant shift. A sign at Cockle Creek, in the state’s far south, reminds visitors that they are closer to Antarctica than to Cairns, invoking a discourse of connectedness that collapses the standard ten-day ship voyage to Australia’s closest Antarctic station into a unit comparable with the routinely scheduled 5.5 hour flight to North Queensland. Hobart is the logistical hub for the Australian Antarctic Division and the French Institut Polaire Francais (IPEV), and has hosted Antarctic vessels belonging to the USA, South Korea, and Japan in recent years. From a far southern perspective, Hobart is not a regional Australian capital but a global polar hub. This alters the city’s geographic imaginary not only in a latitudinal sense—from “top down” to “bottom up”—but also a longitudinal one. Via its southward connection to Antarctica, Hobart is also connected east and west to four other recognized gateways: Cape Town in South Africa, Christchurch in New Zealand; Punta Arenas in Chile; and Ushuaia in Argentina (Image 2). The latter cities are considered small by international standards, but play an outsized role in relation to Antarctica.Image 2: H. Nielsen with a Sign Announcing Distances between Antarctic ‘Gateway’ Cities and Antarctica, Ushuaia, Argentina, 2018. Image Credit: Nicki D'Souza.These five cities form what might be called—to adapt geographer Klaus Dodds’ term—a ‘Southern Rim’ around the South Polar region (Dodds Geopolitics). They exist in ambiguous relationship to each other. Although the five cities signed a Statement of Intent in 2009 committing them to collaboration, they continue to compete vigorously for northern hemisphere traffic and the brand identity of the most prominent global gateway. A state government brochure spruiks Hobart, for example, as the “perfect Antarctic Gateway” emphasising its uniqueness and “natural advantages” in this regard (Tasmanian Government, 2016). In practice, the cities are automatically differentiated by their geographic position with respect to Antarctica. Although the ‘ice continent’ is often conceived as one entity, it too has regions, in both scientific and geographical senses (Terauds and Lee; Antonello). Hobart provides access to parts of East Antarctica, where the Australian, French, Japanese, and Chinese programs (among others) have bases; Cape Town is a useful access point for Europeans going to Dronning Maud Land; Christchurch is closest to the Ross Sea region, site of the largest US base; and Punta Arenas and Ushuaia neighbour the Antarctic Peninsula, home to numerous bases as well as a thriving tourist industry.The Antarctic sector is important to the Tasmanian economy, contributing $186 million (AUD) in 2017/18 (Wells; Gutwein; Tasmanian Polar Network). Unsurprisingly, Tasmania’s gateway brand has been actively promoted, with the 2016 Australian Antarctic Strategy and 20 Year Action Plan foregrounding the need to “Build Tasmania’s status as the premier East Antarctic Gateway for science and operations” and the state government releasing a “Tasmanian Antarctic Gateway Strategy” in 2017. The Chinese Antarctic program has been a particular focus: a Memorandum of Understanding focussed on Australia and China’s Antarctic relations includes a “commitment to utilise Australia, including Tasmania, as an Antarctic ‘gateway’.” (Australian Antarctic Division). These efforts towards a closer relationship with China have more recently come under attack as part of a questioning of China’s interests in the region (without, it should be noted, a concomitant questioning of Australia’s own considerable interests) (Baker 9). In these exchanges, a global power and a state of Australia generally classed as regional and peripheral are brought into direct contact via the even more remote Antarctic region. This connection was particularly visible when Chinese President Xi Jinping travelled to Hobart in 2014, in a visit described as both “strategic” and “incongruous” (Burden). There can be differences in how this relationship is narrated to domestic and international audiences, with issues of sovereignty and international cooperation variously foregrounded, laying the ground for what Dodds terms “awkward Antarctic nationalism” (1).Territory and ConnectionsThe awkwardness comes to a head in Tasmania, where domestic and international views of connections with the far south collide. Australia claims sovereignty over almost 6 million km2 of the Antarctic continent—a claim that in area is “roughly the size of mainland Australia minus Queensland” (Bergin). This geopolitical context elevates the importance of a regional part of Australia: the claims to Antarctic territory (which are recognised only by four other claimant nations) are performed not only in Antarctic localities, where they are made visible “with paraphernalia such as maps, flags, and plaques” (Salazar 55), but also in Tasmania, particularly in Hobart and surrounds. A replica of Mawson’s Huts in central Hobart makes Australia’s historic territorial interests in Antarctica visible an urban setting, foregrounding the figure of Douglas Mawson, the well-known Australian scientist and explorer who led the expeditions that proclaimed Australia’s sovereignty in the region of the continent roughly to its south (Leane et al.). Tasmania is caught in a balancing act, as it fosters international Antarctic connections (such hosting vessels from other national programs), while also playing a key role in administering what is domestically referred to as the Australian Antarctic Territory. The rhetoric of protection can offer common ground: island studies scholar Godfrey Baldacchino notes that as island narratives have moved “away from the perspective of the ‘explorer-discoverer-colonist’” they have been replaced by “the perspective of the ‘custodian-steward-environmentalist’” (49), but reminds readers that a colonising disposition still lurks beneath the surface. It must be remembered that terms such as “stewardship” and “leadership” can undertake sovereignty labour (Dodds “Awkward”), and that Tasmania’s Antarctic connections can be mobilised for a range of purposes. When Environment Minister Greg Hunt proclaimed at a press conference that: “Hobart is the gateway to the Antarctic for the future” (26 Apr. 2016), the remark had meaning within discourses of both sovereignty and economics. Tasmania’s capital was leveraged as a way to position Australia as a leader in the Antarctic arena.From ‘Gateway’ to ‘Antarctic City’While discussion of Antarctic ‘Gateway’ Cities often focuses on the economic and logistical benefit of their Antarctic connections, Hobart’s “gateway” identity, like those of its counterparts, stretches well beyond this, encompassing geological, climatic, historical, political, cultural and scientific links. Even the southerly wind, according to cartoonist Jon Kudelka, “has penguins in it” (Image 3). Hobart residents feel a high level of connection to Antarctica. In 2018, a survey of 300 randomly selected residents of Greater Hobart was conducted under the umbrella of the “Antarctic Cities” Australian Research Council Linkage Project led by Assoc. Prof. Juan Francisco Salazar (and involving all three present authors). Fourteen percent of respondents reported having been involved in an economic activity related to Antarctica, and 36% had attended a cultural event about Antarctica. Connections between the southern continent and Hobart were recognised as important: 71.9% agreed that “people in my city can influence the cultural meanings that shape our relationship to Antarctica”, while 90% agreed or strongly agreed that Hobart should play a significant role as a custodian of Antarctica’s future, and 88.4% agreed or strongly agreed that: “How we treat Antarctica is a test of our approach to ecological sustainability.” Image 3: “The Southerly” Demonstrates How Weather Connects Hobart and Antarctica. Image Credit: Jon Kudelka, Reproduced with Permission.Hobart, like the other gateways, activates these connections in its conscious place-branding. The city is particularly strong as a centre of Antarctic research: signs at the cruise-ship terminal on the waterfront claim that “There are more Antarctic scientists based in Hobart […] than at any other one place on earth, making Hobart a globally significant contributor to our understanding of Antarctica and the Southern Ocean.” Researchers are based at the Institute for Marine and Antarctic Studies (IMAS), the Commonwealth Scientific and Industrial Research Organisation (CSIRO), and the Australian Antarctic Division (AAD), with several working between institutions. Many Antarctic researchers located elsewhere in the world also have a connection with the place through affiliations and collaborations, leading journalist Jo Chandler to assert that “the breadth and depth of Hobart’s knowledge of ice, water, and the life forms they nurture […] is arguably unrivalled anywhere in the world” (86).Hobart also plays a significant role in Antarctica’s governance, as the site of the secretariats for the Commission for the Conservation of Antarctic Marine Living Resources (CCAMLR) and the Agreement on the Conservation of Albatrosses and Petrels (ACAP), and as host of the Antarctic Consultative Treaty Meetings on more than one occasion (1986, 2012). The cultural domain is active, with Tasmanian Museum and Art Gallery (TMAG) featuring a permanent exhibit, “Islands to Ice”, emphasising the ocean as connecting the two places; the Mawson’s Huts Replica Museum aiming (among other things) to “highlight Hobart as the gateway to the Antarctic continent for the Asia Pacific region”; and a biennial Australian Antarctic Festival drawing over twenty thousand visitors, about a sixth of them from interstate or overseas (Hingley). Antarctic links are evident in the city’s natural and built environment: the dolerite columns of Mt Wellington, the statue of the Tasmanian Antarctic explorer Louis Bernacchi on the waterfront, and the wharfs that regularly accommodate icebreakers such as the Aurora Australis and the Astrolabe. Antarctica is figured as a southern neighbour; as historian Tom Griffiths puts it, Tasmanians “grow up with Antarctica breathing down their necks” (5). As an Antarctic City, Hobart mediates access to Antarctica both physically and in the cultural imaginary.Perhaps in recognition of the diverse ways in which a region or a city might be connected to Antarctica, researchers have recently been suggesting critical approaches to the ‘gateway’ label. C. Michael Hall points to a fuzziness in the way the term is applied, noting that it has drifted from its initial definition (drawn from economic geography) as denoting an access and supply point to a hinterland that produces a certain level of economic benefits. While Hall looks to keep the term robustly defined to avoid empty “local boosterism” (272–73), Gabriela Roldan aims to move the concept “beyond its function as an entry and exit door”, arguing that, among other things, the local community should be actively engaged in the Antarctic region (57). Leane, examining the representation of Hobart as a gateway in historical travel texts, concurs that “ingress and egress” are insufficient descriptors of Tasmania’s relationship with Antarctica, suggesting that at least discursively the island is positioned as “part of an Antarctic rim, itself sharing qualities of the polar region” (45). The ARC Linkage Project described above, supported by the Hobart City Council, the State Government and the University of Tasmania, as well as other national and international partners, aims to foster the idea of the Hobart and its counterparts as ‘Antarctic cities’ whose citizens act as custodians for the South Polar region, with a genuine concern for and investment in its future.Near and Far: Local Perspectives A changing climate may once again herald a shift in the identity of the Tasmanian islands. Recognition of the central role of Antarctica in regulating the global climate has generated scientific and political re-evaluation of the region. Antarctica is not only the planet’s largest heat sink but is the engine of global water currents and wind patterns that drive weather patterns and biodiversity across the world (Convey et al. 543). For example, Tas van Ommen’s research into Antarctic glaciology shows the tangible connection between increased snowfall in coastal East Antarctica and patterns of drought southwest Western Australia (van Ommen and Morgan). Hobart has become a global centre of marine and Antarctic science, bringing investment and development to the city. As the global climate heats up, Tasmania—thanks to its low latitude and southerly weather patterns—is one of the few regions in Australia likely to remain temperate. This is already leading to migration from the mainland that is impacting house prices and rental availability (Johnston; Landers 1). The region’s future is therefore closely entangled with its proximity to the far south. Salazar writes that “we cannot continue to think of Antarctica as the end of the Earth” (67). Shifting Antarctica into focus also brings Tasmania in from the margins. As an Antarctic city, Hobart assumes a privileged positioned on the global stage. This allows the city to present itself as central to international research efforts—in contrast to domestic views of the place as a small regional capital. The city inhabits dual identities; it is both on the periphery of Australian concerns and at the centre of Antarctic activity. Tasmania, then, is not in freefall, but rather at the forefront of a push to recognise Antarctica as entangled with its neighbours to the north.AcknowledgementsThis work was supported by the Australian Research Council under LP160100210.ReferencesAntonello, Alessandro. “Finding Place in Antarctica.” Antarctica and the Humanities. Eds. Peder Roberts, Lize-Marie van der Watt, and Adrian Howkins. London: Palgrave Macmillan, 2016. 181–204.Australian Government. Australian Antarctic Strategy and 20 Year Action Plan. Canberra: Commonwealth of Australia, 2016. 15 Apr. 2019. <http://www.antarctica.gov.au/__data/assets/pdf_file/0008/180827/20YearStrategy_final.pdf>.Australian Antarctic Division. “Australia-China Collaboration Strengthens.” Australian Antarctic Magazine 27 Dec. 2014. 15 Apr. 2019. <http://www.antarctica.gov.au/magazine/2011-2015/issue-27-december-2014/in-brief/australia-china-collaboration-strengthens>.Baker, Emily. “Worry at Premier’s Defence of China.” The Mercury 15 Sep. 2018: 9.Baldacchino, G. “Studying Islands: On Whose Terms?” Island Studies Journal 3.1 (2008): 37–56.Barker, Peter F., Gabriel M. Filippelli, Fabio Florindo, Ellen E. Martin, and Howard D. Schere. “Onset and Role of the Antarctic Circumpolar Current.” Deep Sea Research Part II: Topical Studies in Oceanography. 54.21–22 (2007): 2388–98.Bergin, Anthony. “Australia Needs to Strengthen Its Strategic Interests in Antarctica.” Australian Strategic Policy Institute. 29 Apr. 2016. 21 Feb. 2019 <https://www.aspi.org.au/index.php/opinion/australia-needs-strengthen-its-strategic-interests-antarctica>.Boyce, James. 1835: The Founding of Melbourne and the Conquest of Australia. Melbourne: Black Inc., 2011.Burden, Hilary. “Xi Jinping's Tasmania Visit May Seem Trivial, But Is Full of Strategy.” The Guardian 18 Nov. 2014. 19 May 2019 <https://www.theguardian.com/world/2014/nov/18/xi-jinpings-tasmania-visit-lacking-congruity-full-of-strategy>.Bureau of Infrastructure Transport and Regional Economics (BITRE). A Regional Economy: A Case Study of Tasmania. Canberra: Commonwealth of Australia, 2008. 14 May 2019 <http://www.bitre.gov.au/publications/86/Files/report116.pdf>.Chandler, Jo. “The Science Laboratory: From Little Things, Big Things Grow.” Griffith Review: Tasmania: The Tipping Point? 29 (2013) 83–101.Christchurch City Council. Statement of Intent between the Southern Rim Gateway Cities to the Antarctic: Ushuaia, Punta Arenas, Christchurch, Hobart and Cape Town. 25 Sep. 2009. 11 Apr. 2019 <http://archived.ccc.govt.nz/Council/proceedings/2009/September/CnclCover24th/Clause8Attachment.pdf>.Convey, P., R. Bindschadler, G. di Prisco, E. Fahrbach, J. Gutt, D.A. Hodgson, P.A. Mayewski, C.P. Summerhayes, J. Turner, and ACCE Consortium. “Antarctic Climate Change and the Environment.” Antarctic Science 21.6 (2009): 541–63.Cranston, C. “Rambling in Overdrive: Travelling through Tasmanian Literature.” Tasmanian Historical Studies 8.2 (2003): 28–39.Davies, Lynn, Margaret Davies, and Warren Boyles. Mapping Van Diemen’s Land and the Great Beyond: Rare and Beautiful Maps from the Royal Society of Tasmania. Hobart: The Royal Society of Tasmania, 2018.Department of Infrastructure and Regional Development. Guidelines for Analysing Regional Australia Impacts and Developing a Regional Australia Impact Statement. Canberra: Commonwealth of Australia, 2017. 11 Apr. 2019 <https://regional.gov.au/regional/information/rais/>.Dodds, Klaus. “Awkward Antarctic Nationalism: Bodies, Ice Cores and Gateways in and beyond Australian Antarctic Territory/East Antarctica.” Polar Record 53.1 (2016): 16–30.———. Geopolitics in Antarctica: Views from the Southern Oceanic Rim. Chichester: John Wiley, 1997.Griffiths, Tom. “The Breath of Antarctica.” Tasmanian Historical Studies 11 (2006): 4–14.Gutwein, Peter. “Antarctic Gateway Worth $186 Million to Tasmanian Economy.” Hobart: Tasmanian Government, 20 Feb. 2019. 21 Feb. 2019 <http://www.premier.tas.gov.au/releases/antarctic_gateway_worth_$186_million_to_tasmanian_economy>.Hall, C. Michael. “Polar Gateways: Approaches, Issues and Review.” The Polar Journal 5.2 (2015): 257–77. Harwood Andrew. “The Political Constitution of Islandness: The ‘Tasmanian Problem’ and Ten Days on the Island.” PhD Thesis. U of Tasmania, 2011. <http://eprints.utas.edu.au/11855/%5Cninternal-pdf://5288/11855.html>.Hay, Peter. “Destabilising Tasmanian Politics: The Key Role of the Greens.” Bulletin of the Centre for Tasmanian Historical Studies 3.2 (1991): 60–70.Hingley, Rebecca. Personal Communication, 28 Nov. 2018.Johnston, P. “Is the First Wave of Climate Migrants Landing in Hobart?” The Fifth Estate 11 Sep. 2018. 15 Mar. 2019 <https://www.thefifthestate.com.au/urbanism/climate-change-news/climate-migrants-landing-hobart>.Kriwoken, L., and J. Williamson. “Hobart, Tasmania: Antarctic and Southern Ocean Connections.” Polar Record 29.169 (1993): 93–102.Kudelka, John. “The Southerly.” Kudelka Cartoons. 27 Jun. 2014. 21 Feb. 2019 <https://www.kudelka.com.au/2014/06/the-southerly/>.Leane, E., T. Winter, and J.F. Salazar. “Caught between Nationalism and Internationalism: Replicating Histories of Antarctica in Hobart.” International Journal of Heritage Studies 22.3 (2016): 214–27. Leane, Elizabeth. “Tasmania from Below: Antarctic Travellers’ Accounts of a Southern ‘Gateway’.” Studies in Travel Writing 20.1 (2016): 34-48.Mawson’s Huts Replica Museum. “Mission Statement.” 15 Apr. 2019 <http://www.mawsons-huts-replica.org.au/>.Mercer, David. "Australia's Constitution, Federalism and the ‘Tasmanian Dam Case’." Political Geography Quarterly 4.2 (1985): 91–110.Paasi, A. “Deconstructing Regions: Notes on the Scales of Spatial Life.” Environment and Planning A: Economy and Space 23.2 (1991) 239–56.Reddit. “Maps without Tasmania.” 15 Apr. 2019 <https://www.reddit.com/r/MapsWithoutTasmania/>.Roldan, Gabriela. “'A Door to the Ice?: The Significance of the Antarctic Gateway Cities Today.” Journal of Antarctic Affairs 2 (2015): 57–70.Salazar, Juan Francisco. “Geographies of Place-Making in Antarctica: An Ethnographic Epproach.” The Polar Journal 3.1 (2013): 53–71.———, Elizabeth Leane, Liam Magee, and Paul James. “Five Cities That Could Change the Future of Antarctica.” The Conversation 5 Oct. 2016. 19 May 2019 <https://theconversation.com/five-cities-that-could-change-the-future-of-antarctica-66259>.Stratford, Elaine, Godfrey Baldacchino, Elizabeth McMahon, Carol Farbotko, and Andrew Harwood. “Envisioning the Archipelago.” Island Studies Journal 6.2 (2011): 113–30.Tasmanian Climate Change Office. Derivation of the Tasmanian Sea Level Rise Planning Allowances. Aug. 2012. 17 Apr. 2019 <http://www.dpac.tas.gov.au/__data/assets/pdf_file/0003/176331/Tasmanian_SeaLevelRisePlanningAllowance_TechPaper_Aug2012.pdf>.Tasmanian Government Department of State Growth. “Tasmanian Antarctic Gateway Strategy.” Hobart: Tasmanian Government, 12 Dec. 2017. 21 Feb. 2019 <https://www.antarctic.tas.gov.au/__data/assets/pdf_file/0004/164749/Tasmanian_Antarctic_Gateway_Strategy_12_Dec_2017.pdf>.———. “Tasmania Delivers…” Apr. 2016. 15 Apr. 2019 <https://www.antarctic.tas.gov.au/__data/assets/pdf_file/0005/66461/Tasmania_Delivers_Antarctic_Southern_Ocean_web.pdf>.———. “Antarctic Tasmania.” 17 Feb. 2019. 15 Apr. 2019 <https://www.antarctic.tas.gov.au/about/hobarts_antarctic_attractions>.Tasmanian Polar Network. “Welcome to the Tasmanian Polar Network.” 28 Feb. 2019 <https://www.tasmanianpolarnetwork.com.au/>.Terauds, Aleks, and Jasmine Lee. “Antarctic Biogeography Revisited: Updating the Antarctic Conservation Biogeographic Regions.” Diversity and Distributions 22 (2016): 836–40.Van Ommen, Tas, and Vin Morgan. “Snowfall Increase in Coastal East Antarctica Linked with Southwest Western Australian Drought.” Nature Geoscience 3 (2010): 267–72.Wells Economic Analysis. The Contribution of the Antarctic and Southern Ocean Sector to the Tasmanian Economy 2017. 18 Nov. 2018. 15 Apr. 2019 <https://www.stategrowth.tas.gov.au/__data/assets/pdf_file/0010/185671/Wells_Report_on_the_Value_of_the_Antarctic_Sector_2017_18.pdf>.West, J. “Obstacles to Progress: What’s Wrong with Tasmania, Really?” Griffith Review: Tasmania: The Tipping Point? 39 (2013): 31–53.

While the definition of high-dose corticosteroids depends on the indication, it is typically defined as greater than 15–20 mg for greater than 2–4 weeks. Corticosteroids have a variety of indications such as autoimmune, gastrointestinal, rheumatologic, respiratory, and hematologic conditions and after organ or hematopoietic stem cell transplantation. They can predispose these patients to infections such as pneumococcal pneumonia, Pneumocystis jirovecii (carinii) pneumonia (PJP), hepatitis B reactivation, active tuberculosis, and disseminated strongyloides infection. This article outlines ways to modify these risks in these patients. Prophylaxis is of utmost importance to those at risk for PJP with trimethoprim/sulfamethoxazole, lamivudine for those at risk of hepatitis B reactivation, isoniazid (INH) for latent tuberculosis and ivermectin for those with positive strongyloides serology. Equally important in mitigating disease risk is the appropriate timing of vaccines to elicit an adequate immune response as well as offering additional vaccines such as the pneumococcal vaccine.RésuméLa notion de dose élevée de corticostéroïdes varie selon les indications, mais elle est généralement définie comme correspondant à plus de 15‑20 mg sur une période de plus de deux à quatre semaines. Les corticostéroïdes sont indiqués dans nombre de conditions auto‑immunes, gastro-intestinales, rhumatologiques, respiratoires et hématologiques, ainsi qu’à la suite d’une transplantation d’organe ou de cellules souches hématopoïétiques. Ils peuvent toutefois prédisposer les patients à diverses infections comme la pneumonie pneumococcique et la pneumonie à Pneumocystis jirovecii (carinii) ou PCP, à une réactivation de l’hépatite B, à une tuberculose active et à une strongyloïdose disséminée. Le présent article passe en revue différentes façons de réduire ces risques chez les patients concernés. Voici des mesures de prophylaxie qui s’avèrent être de la plus haute importance pour les personnes à risque : le triméthoprime ou le sulfaméthoxazole pour celles à risque de PCP; la lamivudine pour celles à risque de réactivation de l’hépatite B; l’isoniazide (INH) dans les cas de tuberculose latente; et l’ivermectine pour les personnes montrant une sérologie positive aux strongyloïdes. De plus, pour réduire le risque de maladie, un calendrier de vaccination approprié est tout aussi important, en vue de susciter une réponse immunitaire adéquate et de pouvoir offrir d’autres vaccins comme le vaccin antipneumococcique.Corticosteroids were first used in clinical practice in 1949 for rheumatoid arthritis.1 The number of patients on high-dose corticosteroids is not well known but the use of corticosteroids is becoming increasingly common for a number of indications: An estimated 1% of the general population in the UK is treated with corticosteroids, and this rate increases with age to almost 2.5% in those aged 70–79. 4“High-dose corticosteroids” as a risk factor for infections is typically defined as greater than 15–20 mg of prednisone (or its’ equivalent) for greater than 2–4 weeks, although this definition does vary slightly depending on the infection considered. Notably, this definition is different from the standard definition of high-dose corticosteroids for treatment purposes used in the literature – which is usually defined as greater than 30 mg but less than 100 mg/day – as this dose results in almost complete cytosolic receptor saturation. 2Corticosteroids are used commonly for their anti-inflammatory effects in many conditions with an element of autoimmune disease. The mechanism is to induce transient lymphocytopenia by altering lymphocyte circulation, inducing lymphocyte death and inhibiting cytokines to prevent T-cell activation.3 For example, they are used to induce remission in inflammatory bowel disease (IBD) or to maintain symptom control in rheumatologic diseases like polymyalgia rheumatica. They are also used to prevent organ rejection in solid organ transplantation. Other indications include autoimmune hepatitis, other rheumatologic diseases such as rheumatoid arthritis, systemic lupus erythematous, vasculitis, respiratory conditions such as interstitial lung disease, sarcoidosis, hematologic disorders such as lymphoma, leukemia, idiopathic thrombocytopenic purpura, hemolytic anemia), endocrine disorders like Graves disease to prevent opthalmopathy and other conditions like multiple sclerosis.The relative risk of bacterial infections was found to be 5-fold higher in IBD patients on corticosteroids alone, 4-fold higher for other infections like strongyloides and tuberculosis, and only 1.5 fold higher for viral infections.5 However, the absolute individual risk of infectious complications from corticosteroid use remains fairly small. Nevertheless, the burden is significant at a population level due to the high frequency of corticosteroid use. 4 Thus, most practitioners eventually come across these complications during their career.VaccinationsOne of the first considerations in patients on high-dose corticosteroids is the timing of the administration of vaccines to be given to these patients. Immunizations with inactivated vaccines can be given up to 2 weeks before high-dose corticosteroids are initiated, whereas live vaccines need to be given 4 weeks before the high-dose corticosteroids are begun. If the vaccines cannot be given prior to the start of a corticosteroid treatment, both live and inactivated vaccines must wait for 4 weeks after the steroids are completed to elicit an adequate immune response and prevent infectious complications with live vaccines.6Equally important to the timing of the vaccines, patients on high-dose corticosteroids (defined as anyone receiving ³ 20 mg/day for 14 days or more) should receive additional vaccines. A single dose of an inactivated pneumococcal conjugate vaccine (Prevnar), at least one year after any previous dose of pneumococcal vaccine polyvalent (Pneumovax), followed by a single dose of Pneumovax 8 weeks later with a booster of Pneumovax 5 years later is recommended for those on high-dose corticosteroids.7,8 Pneumocystis jiroveci infectionThe following patient groups are considered to be at higher risk forPneumocystis jiroveci pneumonia (PJP; formerly known as Pneumocystis carinii pneumonia [PCP])if exposed to prednisone at doses as low as 20 mg/day for at least 4 weeks9: patients with an underlying immunosuppressive disorder (including autologous HSCT and malignancy), or those with chronic obstructive pulmonary disease and interstitial lung disease secondary to polymyositis/dermatomyositis. Also, patients receiving the same dose of prednisone plus TNF-alpha inhibitors, cyclophosphamide, methotrexate, or temsirolimus should also receive PJP prophylaxis. The first-line agent for prophylaxis is trimethoprim/sulfamethoxazole 80/400 mg (single strength) daily or 160/800 mg (double strength) three times per week (e.g., Monday/Wednesday/Friday). While adverse events are rare on such low doses, thrombocytopenia is possible given that this is an idiosyncractic reaction but pancytopenia is usually observed at much higher (i.e., treatment) doses. Also possible are hyperkalemia, increased serum creatinine and aseptic meningitis. A more rare but devastating adverse event is Stevens-Johnson syndrome. A second line agent for PJP prophylaxis is dapsone but this requires glucose-6-phosphate dehydrogenase (G6PD) testing first, as those who are deficient in this erythrocytic enzyme show a two-fold higher predisposition to dapsone-induced hemolytic anemia. Other alternatives for PJP prophylaxis are atovaquone 1500 mg daily, but this is a costly option, or inhaled pentamidine via a nebulizer at 300 mg every month. Correct administration of inhaled pentamidine is crucial and due to the route of administration, disseminated PCP disease is still possible. 9 Hepatitis B ReactivationFurthermore, patients on corticosteroids of at least 20 mg/day for at least 4 weeks, have an 11–20% chance of reactivation if they are hepatitis B surface Ag carriers. An inactive carrier is hepatitis B surface antigen positive for greater than 6 months without detectable hepatitis B e antigen (HbeAg), presence of anti-hepatitis B e antibodies (anti-Hbe), and undetectable or low levels of hepatitis B DNA, repeatedly normal ALT levels, and no or minimal liver fibrosis. Inactive carriers comprise the largest group of chronic hepatitis B infected individuals with an estimated 250 million people worldwide and can convert to active disease under such immunosuppression.Therefore, it is prudent to prescribe hepatitis B prophylaxis to these patients although no high-level evidence supporting this approach is available.11 Lamivudine is considered first choice for these patients if they do not otherwise meet treatment criteria for hepatitis B. Tenofovir is considered first line in areas highly prevalent for resistance to lamivudine, which tends to occur with prolonged lamivudine exposure. For example, lamivudine resistance develops in up to 90% of HBV-HIV co-infected individuals after 4 years of lamivudine therapy.12.In the setting of isolated anti-Hb-core antibody positivity, prophylaxis is not recommendedgiven that the rate of reactivation is less than 1%.10 Instead, patients should have serial measurements of liver function, hepatitis B serology and hepatitis B DNA every 1–3 months during the period of immunosuppressive treatment and if there is any elevation in these markers, antiviral prophylaxis or treatment (depending on the results) should be offered.So, when assessing patients for the need for PCP or hepatitis B prophylaxis, both the intended duration as well as the dose of the corticosteroids need to be considered.Strongyloides stercoralis InfectionStrongyloides stercoralis can persist for several decades and can reactivate with glucocorticoid exposure causing a severe and sometimes fatal disseminated infection. Strongyloides infection can be asymptomatic and can be acquired walking barefoot on soil in the developing world.13 Strongyloides serology is therefore recommended for refugees from low-income countries in Southeast Asia and Africa where strongyloides is endemic before starting high-dose corticosteroid treatement.14 If positive, patients should be treated with 2 doses of ivermectin to prevent the development of hyperinfection. TuberculosisPatients with latent tuberculosis on higher dose and/or longer duration of glucocorticoid use are also at risk of conversion to active disease. A one-step tuberculin skin test (TST) ³ 5 mm is considered positive when a patient is on prednisone doses ³ 15 mg/day for one month or more. First-line treatment for latent tuberculosis is isoniazid over 9 months. Patients should begin therapy ideally at least 4 weeks before starting such immunosuppression to prevent conversion to active disease.15,16. If this is not possible, the recommendation is to start isoniazid and the corticosteroids at the same time. ConclusionsSerious and potentially fatal infections are just one of the many potential complications of being on high-dose corticosteroids for a long period of time – others include diabetes, hypertension, psychosis, osteoporosis, adrenal insufficiency and the development of cushingoid features.17 Infectious diseases that are either latent or inactive may reactivate under high-dose corticosteroids including tuberculosis, pneumocystis jirovecii pneumonia, Strongyloides stercoralis, and hepatitis B. Screening and treatment for such conditions prior to starting high-dose corticosteroids, or at least once the corticosteroids are started, can prevent these complications. Furthermore, the timing of both inactivated and live vaccines is crucial for the patients’ ability to mount an appropriate immune response and to avoid complications from live vaccines. Finally, patients on high-dose corticosteroids are at higher risk for illnesses that may require additional vaccinations not otherwise given to such individuals – for example the pneumococcal vaccine.DisclosureThere are no conflicts of interest for either author on this manuscript. References1. Zoorob RJ and Cender D. A different look at corticosteroids. American Family Physician. 1998 Aug 1; 58(2): 443-450. 2. Buttgereit F, Da Silva JAP, Boers M et al. Standardised nomenclature for glucocorticoid dosages and glucocorticoid treatment regimens: current questions and tentative answers in rheumatology. Ann Rheum Dis 2002; 61: 718-722. 3.Hall BM and Hodgkinson SJ. Corticosteroids in autoimmune diseases. Aust Prescr 1999; 22: 9-11. 4. T.P. van Staa, H.G. Leufkens, L. Abenhaim, B. Begaud, B. Zhang, C. Cooper. Use of oral corticosteroids in the United Kingdom. QJM. 2000 Feb; 93(2): 105–111. 5. Paul Brassard, Alain Bitton, Alain Suissa, Liliya Sinyavskaya, Valerie Patenaude and Samy Suissa. Oral Corticosteroids and the Risk of Serious Infections in Patients With Elderly-Onset Inflammatory Bowel Diseases. The American Journal of Gastroenterology. 2014 Nov; 109: 1795-1802. 6. PHAC: Canadian Immunization Guide - section 3 - Vaccination of specific populations (acquired/secondary immunodeficiency) - http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-07-eng.php#a4. Accessed July 19 2015. Modified December 5th 2013. 7. PHAC: Canadian Immunization Guide – Section 4 – Active Vaccines: Pneumococcal Vaccine - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-pneu-eng.php#tab1. Accessed July 19 2015. Modified March 24th 2015. 8. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012 Oct 12; 61(40): 816. 9. Tomblyn M, Chiller T, Einsele H at al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009; 15(10): 1143. 10. Di Bisceglie AM, Lok AS, Martin P, Terrault N, Perrillo RP, Hoofnagle JH. Recent US Food and Drug Administration warnings on hepatitis B reactivation with immune-suppressing and anticancer drugs: just the tip of the iceberg? Hepatology. 2015; 61(2): 703. 11. Cheng J, Li JB, Sun QL et al. Reactivation of Hepatitis B Virus After Steroid Treatment in Rheumatic Diseases. The Journal of Rheumatology. 2011; 38 (1): 181-182. 12. Benhamou Y, Bochet M, Thibault V, et al. Long-term incidence of hepatitis B virus resistance to lamivudine in human immunodeficiency virus-infected patients. Hepatology. 1999; 30: 1302-1306. 13. Farthing M, Fedail S, Savioli L et al. WGO Practice Guideline: Management of strongyloides. 2004. 14. Khan K, Heidebrecht C, Sears J et al. Appendix 8: Intestinal parasites – Strongyloides and Schistosoma: evidence review for newly arriving immigrants and refugees. CMAJ . 2011; 183(12): E824-925. 15. Pai M, Kunimoto D, Jamieson F, et al. Canadian Tuberculosis Standards – 7th edition. Centre for Communicable Diseases and Infection Control - Public Health Agency of Canada. February 2014: 75. 16. Singh JA, Furst DE, Bharat A et al. 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis. Arthritis Care & Research 2012; 64(5): 625–639. 17. Liu D, Ahmet A, Ward L et al. A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy, Asthma & Clinical Immunology. 2013, 9:30.

The old “Is the glass half empty or half full?” question does more than just illustrate a person’s proclivity for pessimism or for optimism. It alerts us to the possibility that the same real world phenomena may be interpreted in entirely different ways, with very real consequences. It is this notion that I apply to the way fat sex and thin sex are conceptualised in the larger social consciousness. While sexual, romantic and/or intimate acts between people where at least one individual is fat (Fat Sex) are deemed atypical, abnormal, fetishistic and even abusive (Saguy qtd. in Swami & Tovee 90; Schur qtd. in Prohaska 271; Gailey 119), such encounters between able-bodied individuals who are thin or of average weight (Thin Sex) are deemed normal and desirable. I argue in this article that this discrepancy in how we label and treat fat and thin sexuality is unjustified because the two domains are more similar than distinct. Given their similarity we should treat similar aspects of both domains in the same way, i.e. either as normal, or as fetishistic based on relevant criteria rather than body size. I also argue that fat prejudice and thin privilege underlie this discrepancy in modern western society. I finally conclude that this causes significant personal and social harm to both fat and thin individuals.Fat Sex – The Fetishized NormalHanne Blank, in writing of her foray into publishing body positive material exploring fat sexuality, speaks of the need for spaces that acknowledge the vitality and diversity of fat sex; not in fetishistic and pornographic portrayals of Big Beautiful Women offering themselves up as an object of desire but reflecting the desires and sexual experiences of fat people themselves (10). If there are a 100 million people in America who are obese according to BMI standards, she argues, they represent a whole array of body sizes and a lot of sexual activity, which she describes as follows:Fat people have sex. Sweet, tender, luscious sex. Sweaty, feral, sheet-ripping sex. Shivery, jiggly, gasping sex. Sentimental, slow, face-cradling sex. Even as you read these words, there are fat people out there somewhere joyously getting their freak on. Not only that, but fat people are falling in love, having hook-ups, being crushed-out, putting on sexy lingerie, being the objects of other people’s lust, flirting, primping before hot dates, melting a little as they read romantic notes from their sweeties, seducing and being seduced, and having shuddering, toe-curling orgasms that are as big as they are. It’s only natural. (15)Such normalcy and diverse expression, however, is not usually portrayed in popular media, nor even in much scholarly research. Apart from body positive spaces carved out by the fat acceptance movement online and the research of fat studies scholars, which, contextualises fat sexuality as healthy and exciting, in “the majority of scholarship on this topic, fat women’s sexual behaviors are never the result of women’s agency, are always the result of their objectification, and are never healthy” (Prohaska 271).This interpretation of fat sexuality, the assumptions associated with it and the reinforcement of these attitudes have much to do with the pervasiveness of fat prejudice in society today. One study estimates that the prevalence of weight based discrimination in the US increased by 66% between 1996 and 2006 (Andreyeva, Puhl and Brownell) and is now comparable to gender and race based discrimination (Puhl, Andreyeva and Brownell). This is not an isolated trend. An anthropological study analysing the globalisation of notions of fat being unhealthy and a marker of personal and social failing suggests that we have on our hands a rapidly homogenising global stigma associated with fat (Brewis, Wutich and Rodriguez-Soto), a climate of discrimination leading many fat people to what Goffman describes as a spoiled identity (3).Negative stereotypes affecting fat sexuality are established and perpetuated through a process of discursive constraint (Cordell and Ronai 30-31). “’No man will ever love you,’ Weinstein’s grandmother informs her (Weinstein, prologue), simultaneously offering her a negative category to define herself by and trying to coerce her into losing weight – literally constraining the discourse that Weinstein may apply to herself.Discursive constraint is created not only by individuals reinforcing cultural mores but also by overt and covert messages embedded in social consciousness: “fat people are unattractive”, “fat is ugly”, “fat people are asexual”, “fat sex is a fetish”, “no normal person can be attracted to a fat person”. Portrayals of fat individuals in mainstream media consolidate these beliefs.One of the most loved fat characters of 1990s, Fat Monica from the sitcom Friends is gluttonous, ungainly (rolling around in a bean bag, jolting the sofa as she sits), undesirable (Chandler says to Ross, “I just don’t want to be stuck here all night with your fat sister!”), and desperate for sex, affection and approval from the opposite sex: “the comedic potential of Fat Monica is premised on an understanding that her body is deviant or outside the norm” (Gullage 181).In Shallow Hal, a film in which a shallow guy falls in love with the inner beauty of a fat girl, Hal (Jack Black) is shown to be attracted to Rosemary (Gwyneth Paltrow) only after he can no longer see her real fat body and her “inner beauty” is represented by a thin white blond girl. All the while, the movie draws laughs from the audience at the fat jokes and gags made at the expense of Paltrow’s character.Ashley Madison, a website for married people looking to have an affair, used the image of a scantily clad fat model in an advertisement with the tagline “Did your wife scare you last night?”, implying that infidelity is justified if you’re not attracted to your partner, and fatness precludes attraction. And a columnist from popular magazine Marie Claire wrote about Mike and Molly, a sitcom about two fat people in a relationship:Yes, I think I'd be grossed out if I had to watch two characters with rolls and rolls of fat kissing each other ... because I'd be grossed out if I had to watch them doing anything. (Kelly)It is the prevalence of these beliefs that I call the fetishisation of fat sexuality. When fat bodies are created as asexual and undesirable, it gives rise to the rhetoric that to be sexually attracted to a fat body is unnatural, therefore making any person who is attracted to a fat body a fetishist and the fat person themselves an object of fetish.The internalisation of these beliefs is not only something that actively harms the self-esteem, sexual agency & health and happiness of fat individuals (Satinsky et al.), but also those who are attracted to them. Those who internalise these beliefs about themselves may be unable to view themselves as sexual and engage with their own bodies in a pleasurable manner, or to view themselves as attractive, perhaps discounting any assertions to the contrary. In a study designed to investigate the relationship between body image and sexual health in women of size, one participant revealed:I’ve had my issues with T as far as um, believing that T is attracted to me…because of my weight, my size and the way I look. (Satinsky et al. 717)Another participant speaks of her experience masturbating and her discomfort at touching her own flesh, leading her to use a vibrator and not her hands:Like, I don’t, I don’t look down. I look at the ceiling and I try to – it’s almost like I’m trying to imagine that I was thinner. Like, imagine that my stomach was flatter or something like that, which sounds bizarre, but I guess that’s what I’m trying to do. (Satinsky et al. 719)Others stay in bad marriages because they believe they wouldn’t find anyone else (Joanisse and Synnott 55) or tolerate abuse because of their low self-esteem (Hester qtd. in Prohaska 271).Similarly, men who internalise these attitudes about fat find it easier to dehumanise and objectify fat women, believe that they’d be desperate for sex and hence an easy target for a sexual conquest, and are less deserving of consideration (Prohaska and Gailey 19).On the other hand, many men who find fat women attractive (Fat Admirers or FA’s) remain closeted because their desire is stigmatised. Many do not make their preference known to their peer group and families, nor do they publicly acknowledge the woman they are intimate with. Research suggests that FA’s draw the same amount of stigma for being with fat women and finding them attractive, as they would for themselves being fat (Goode qtd. in Prohaska and Gailey).I do not argue here that all fat individuals have spoiled identities or that all expressions of fat sexuality operate from a place of stigma and shame, but that fat sexuality exists within a wider social fabric of fat phobia, discrimination and stigmatisation. Fulfilling sexual experience must therefore be navigated within this framework. As noted, the fat acceptance movement, body positive spaces online, and fat studies scholarship help to normalise fat sexuality and function as tools for resisting stigma and fetishisation.Resisting Stigma: Creating Counter NarrativesGailey, in interviews with 36 fat-identified women, found that though 34 of them (94%) had ‘experienced a life of ridicule, body shame and numerous attempts to lose weight’ which had an adverse effect on their relationships and sex life, 26 of them reported a positive change after having ‘embodied the size acceptance ideology’ (Gailey 118).Recently, Kristin Chirico, employee of Buzzfeed, released first an article and then a video titled My Boyfriend Loves Fat Women about her relationship with her boyfriend who loves fat women, her own discomfort with her fatness and her journey in embracing size acceptance ideologies: I will let him enjoy the thing he loves without tearing it down. But more importantly, I will work to earn love from me, who is the person who will always play the hardest to get. I will flirt as hard as I can, and I will win myself back.Books such as Wann’s Fat!So?, Blank’s Big Big Love: A Sex and Relationships Guide for People of Size (and Those Who Love Them), Chastain’s Fat: The Owner’s Manual and her blog Dances with Fat, Tovar’s Hot and Heavy: Fierce Fat Girls on Life, Love and Fashion, as well as Substantia Jones’s fat photography project called The Adipositivity Project are some examples of fat activism, size acceptance and body positive spaces and resources. The description on Jones’s site reads:The Adipositivity Project aims to promote the acceptance of benign human size variation and encourage discussion of body politics, not by listing the merits of big people, or detailing examples of excellence (these things are easily seen all around us), but rather through a visual display of fat physicality. The sort that's normally unseen. When fat individuals create personal narratives to resist stigmatisation of fat sexuality they confront the conundrum of drawing the line between sexual empowerment and glorifying fat fetishism. To see one’s own and other fat bodies as sexual, normal and worthy of pleasure is one way to subvert this fetishism. One would also take seriously any sexual advances, seeing oneself as desirable. The line between normal expression of fat sexuality and the wide spread belief that fat sex is fetishistic is so blurred however, that it becomes difficult to differentiate between them, so it is common to ask if one is being sexual or being an object of fetish. There is also the tension between the heady sense of power in being a sexual agent, and the desire to be wanted for more than just being a fat body.Modern burlesque stage is one arena where fat bodies are being recreated as sexy and desirable, offering a unique resource to ‘fat performers and audience members who want to experience their bodies in new and affirming ways’. Because burlesque is an erotic dance form, fat women on the burlesque stage are marked as ‘sexual, without question or challenge’. The burlesque stage has a great capacity to be a space for transforming sexual identity and driving changes in audience attitudes, creating a powerful social environment that is contrary to mainstream conditions in society (Asbill 300).The founder and creative director of “Big Burlesque” and “Fat-Bottom Revue” the world’s first all-fat burlesque troupe, however, notes that when she started Big Burlesque there were a couple of “bigger” performers on the neo-burlesque circuit, but they did not specifically advocate fat liberation. ‘Fat dance is rare enough; fat exotic/erotic dance is pretty much unheard of outside of “fetish” acts that alienate rather than normalise fat bodies’ (McAllister 305).In another instance, Laura writes that to most men her weight is a problem or a fetish, constraining the potential in relationships. Speaking of BBW (Big Beautiful Women) and BHM (Big Handsome Men) websites that cater to Fat Admirers she writes:As I’ve scrolled through these sites, I’ve felt vindicated at seeing women my size as luscious pinups. But, after a while, I feel reduced to something less than a person: just a gartered thigh and the breast-flesh offered up in a corset. I want to be lusted after. I want to be wanted. But, more than this, I want to love, and be loved. I want everything that love confers: being touched, being valued and being seen.That sexual attraction might rely wholly or partly on physical attributes, however, is hardly unfamiliar, and is an increasing phenomenon in the wider culture and popular media. Of course, what counts there is being thin and maintaining the thin state!Thin Sex: The Normalised FetishUnlike the fat body, the thin body is created as beautiful, sexually attractive, successful and overwhelmingly the norm (van Amsterdam). Ours is a culture fixated on physical beauty and sex, both of which are situated in thin bodies. Sexiness is a social currency that buys popularity, social success, and increasingly wealth itself (Levy). Like fat sex, thin sex operates on the stage set by the wider cultural ideals of beauty and attractiveness and that of the burden of thin privilege. Where stigma situates fat sexuality to abnormality and fetish, thin sexuality has to deal with the pressures of conforming to and maintaining the thin state (vam Amsterdam).Thin individuals also deal with the sexualisation of their bodies, confronting the separation of their personhood from their sexuality, in a sexual objectification of women that has long been identified as harmful. Ramsey and Hoyt explore how being objectified in heterosexual relationships might be related to coercion within those relationships. Their evidence shows that women are routinely objectified, and that this objectification becomes part of the schema of how men relate to women. Such a schema results in a fracturing of women into body parts dissociated from their personhood , making it easier to engage in violence with, and feel less empathy for female partners (in cases of rape or sexual assault). (Ramsey and Hoyt) What is interesting here is the fact that though aspects of thin sexuality are recognised as fetishistic (objectification of women), thin sex is still considered normal.Thin Sex, Fat Sex and 50 Shades of OverlapThe normalisation of sexual objectification -- society for the most part being habituated to the fetishistic aspects of thin sex, can be contrasted with attitudes towards comparable aspects of fat sex. In particular, Feederism, is generally viewed within scholarly discourse (and public attitudes) as ‘a consensual activity, a fetish, a stigmatised behaviour, and abuse’ (Terry & Vassey, Hester, Bestard, Murray as qtd. in Prohaska 281). Prohaska argues that Feederism and Diet Culture are broadly similar phenomena that elicit tellingly opposing judgements. She reports that the culture of feederism (as analysed on online forums) is a mostly consensual activity, where the community vocally dissuades non-consensual activities and any methods that may cause bodily harm (268). It is mostly a community of people who discuss measures of gradual weight gain and support and encourage each other in those goals. This, she argues, is very similar in tone to what appears on weight loss websites and forums (269). She contends, however that despite these parallels ‘the same scrutiny is not given to those who are attempting to lose weight as is placed upon those who do not diet or who try to gain weight’ (269).She notes that whereas in judging feederism emphasis is on fringe behaviours, in evaluating diet culture the focus is on behaviours deemed normal and healthy while only disorders like anorexia, bulimia, and pill using are judged fringe behaviours. This disparity, she claims, is rooted in fat phobia and prejudice (270).In comparing the dating sections of feederism websites with mainstream dating sites she notes that here too the nature of ads is similar, with the only difference being that in mainstream sites the body size preference is assumed. People seeking relationships on both kinds of sites look for partners who are ‘caring, intelligent and funny’ and consider ‘mutual respect’ as key (270).This is similar to what was revealed in an article by Camille Dodero, who interviewed a number of men who identify as fat admirers and delved into the myths and realities of fat admiration. The article covers stories of stigma that FA’s have faced and continue to face because of their sexual preference, and also of internalised self-hatred that makes it difficult for fat women to take their advances seriously. The men also create BBW/BHM dating websites as more than a fetish club. They experience these online spaces as safe spaces where they can openly meet people they would be interested in just as one would on a normal/mainstream dating site. Even if most women fit the type that they are attracted to in such spaces, it does not mean that they would be attracted to all of those women, just as on match.com one would look over prospective candidates for dating and that process would include the way they look and everything else about that person.Attempting to clear up the misconception that loving fat women is a fetish, one of the interviewees says,“Steve, over there, has a type,” gesturing wanly at a stranger in a hockey jersey probably not named Steve. “I have a type, too. Mine’s just bigger. He may like skinny blondes with bangs and long legs. I like pear shapes with brown hair and green eyes. I have a type—it just happens to be fat.” Besides, people aren’t fetish objects, they’re people. “It’s not like having a thing for leather.” (Dodero 3)ConclusionAnalysis of the domains of thin and fat sex shows that both have people engaging in sexual activity and romantic and intimate relationships with each other. Both have a majority of individuals who enjoy consensual, fulfilling sex and relationships, however these practices and desires are celebrated in one domain and stigmatised in the other. Both domains also have a portion of the whole that objectifies relationship partners with immense potential for harm, whether this involves sexualisation and objectification and its related harms in thin sex, objectification of fat bodies in some BBW and BHM circles, and the fringes of feederism communities, or non-body size specific fetish acts that individuals from both domains engage in. Qualitatively, since both domains significantly overlap, it is difficult to find the justification for the fetishisation of one and the normativity of the other. It seems plausible that this can be accounted for by the privilege associated with thin bodies and the prejudice against fat.Our failure to acknowledge such fetishisation of normal fat sex and normalisation of the fetishistic aspects of thin sex creates huge potential for harm for both groups, for it not only causes the fragmentation of effort when it comes to addressing these issues but also allows for the rich vitality and diversity of “normal” fat sex to wallow in obscurity and stigma.References Andreyeva, Tatiana, Rebecca M. Puhl, and Kelly D. Brownell. "Changes in Perceived Weight Discrimination among Americans, 1995–1996 through 2004–2006." Obesity 16 (2008): 1129-1134.Asbill, D. Lacy. "'I’m Allowed to Be a Sexual Being': The Distinctive Social Conditions of the Fat Burlesque Stage." The Fat Studies Reader, eds. Sondra Solovay and Esther Rothblum. New York: New York UP, 2009. 299.Blank, Hanne. Big Big Love, Revised, A Sex and Relationship Guide for People of Size (and Those Who Love Them). New York: Celestial Arts, 2011.Bogart, Laura. Salon 4 Aug. 2014.Brewis, A.A., A. Wutich and I. Rodriguez-Soto. "Body Norms and Fat Stigma in Global Perspective." Current Anthropology 52 (2011): 269-276.Chirico, Kristin. My Boyfriend Loves Fat Women. 25 Feb. 2015.Cordell, Gina, and Carol Rambo Ronai. "Identity Management among Overweight Women: Narrative Resistance to Stigma." Interpreting Weight: The Social Management of Fatness and Thinness, eds. Jeffery Sobal and Donna Maurer. Transaction Publishers, 1999. 29-48. Dodero, Camille. Guys Who Like Fat Chicks. 4 May 2011.Prohaska, Ariane, and Jeannine A. Gailey. "Achieving Masculinity through Sexual Predation: The Case of Hogging." Journal of Gender Studies 19.1 (2010): 13-25.Gailey, Jeannine A. “Fat Shame to Fat Pride: Fat Women’s Sexual and Dating Experiences.” Fat Studies: An Interdisciplinary Journal of Body Weight and Society 1.1 (2012). Goffman, Erving. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, N.J: Prentice-Hall, 1963.Gullage, Amy. "Fat Monica, Fat Suits and Friends." Feminist Media Studies 14.2 (2012): 178-89. Jacqueline. "I'm The 'Scary' Model in That Awful Ashley Madison Ad." 11 July 2011. Online. 24 May 2015.Jones, Substantia. The Adipositivity Project. n.d. Kelly, M. "Should 'Fatties' Get a Room? (Even on TV?)" 2010.Levy, Ariel. "Raunch Culture." Female Chauvinist Pigs: Women and the Rise of Raunch Culture. New York: Free Press, 2005. 7-45.McAllister, Heather. "Embodying Fat Liberation." The Fat Studies Reader, eds. Sondra Solovay and Esther Rothblum. New York: New York UP, 2009. 305.Prohaska, Ariane. “Help Me Get Fat! Feederism as Communal Deviance on the Internet.” Deviant Behaviour 35.4 (2014). Puhl, Rebecca M., Tatiana Andreyeva, and Kelly Brownell. "Perceptions of Weight Discrimination: Prevalence and Comparison to Race and Gender Discrimination in America." International Journal of Obesity 32 (2008): 992-1000.Ramsey, Laura R., and Tiffany Hoyt. "The Object of Desire: How Being Objectified Creates Sexual Pressure for Women in Heterosexual Relationships." Psychology of Women Quarterly (2014): 1-20.Satinsky, Sonya, et al. "'Fat Girl Complex': A Preliminary Investigation of Sexual Health and Body Image in Women of Size." Culture, Health and Sexuality: An International Journal for Research, Intervention and Care 15.6 (2013): 710-25.Swami, Viren, and Martin J. Tovee. “Big Beautiful Women: The Body Size Preferences of Male Fat Admirers.” The Journal of Sex Research 46.1 (2009): 89-86.Joanisse, Leanne, and Anthony Synnott. "Fighting Back: Reactions and Resistance to the Stigma of Obesity." Interpreting Weight: The Social Management of Fatness and Thinness, eds. Jeffery Sobal and Donna Maurer. New York: First Transaction Printing, 2013. 49-73.Van Amsterdam, Noortje. "Big Fat Inequalities, Thin Privilege: An Intersectional Perspective on 'Body Size'." European Journal of Women's Studies 20.2 (2013): 155-69.Weinstein, Rebecca Jane. “Fat Sex: The Naked Truth”. EBook, 2012.

Cultural Studies has tended to prioritise the domain of leisure and consumption over work as an area for meaning making, in many ways defining everyday life in opposition to work. Greg Noble, a cultural researcher who examined work in the context of the early computerisation of Australian universities made the point that "discussions of everyday life often make the mistake of assuming that everyday life equates with home and family life, or leisure" (87). This article argues for the need within Cultural Studies to focus on work and media as a research area of everyday life. With the growth of flexible and creative labour and the widespread uptake of an array of new media technologies used for work, traditional ways to identify and measure the space and time of work have become increasingly flawed, with implications for how we account for work and negotiate its boundaries. New approaches are needed to address the complex media environments and technological practices that are an increasing part of contemporary working life. Cultural Studies can make a significant impact towards this research agenda by offering new ways to analyse the complex interrelations of space, time and technology in everyday work practice. To further this goal, a new material practices account of work termed Officing is introduced, developed through my doctoral research on professionals' daily use of information and communication technology (ICT). This approach builds on the key cultural concepts of "bricolage" and "appropriation" combined with the idea of "articulation work" proposed by Anselm Strauss, to support the analysis of the office workplace as a contingent and provisional arrangement or process. Officing has a number of benefits as a framework for analysing the nature of work in a highly mediated world. Highlighting the labour that goes into stabilising work platforms makes it possible to assess the claims of productivity and improved work-life balance brought about by new mobile media technologies; to identify previously unidentified sources of time pressure, overwork and intensification and ultimately, to contribute to the design of more sustainable work environments. The Turn Away from Work Work held a central position in social and cultural analysis in the first half of the twentieth century but as Strangleman observed, there was a marked shift away from the study of work from the mid 1970s (3.1). Much of the impulse for this shift came from critiques of the over-emphasis on relations of production and the workplace as the main source of meaning and value (5.1). In line with this position, feminist researchers challenged the traditional division of labour into paid and unpaid work, arguing that this division sustained the false perception of domestic work as non-productive (cf. Delphy; Folbre). Accompanying these critiques were significant changes in work itself, as traditional jobs literally began to disappear with the decline of manufacturing in industrialised countries (6.1). With the turn away from work in academia and the changes in the nature of work, attention shifted to the realm of the market and consumption. One of the important contributions of Cultural Studies has been the focus on the role of the consumer in driving social and technological change and processes of identity formation. Yet, it is a major problem that work is largely marginalised in cultural research of everyday life, especially since, in most industrialised nations, we are working in new ways, in rapidly changing conditions and more than ever before. Research shows that in Australia there has been a steady increase in the average hours of paid work and Australians are working harder (cf. Watson, Buchanan, Campbell and Briggs; Edwards and Wajcman). In the 2008 Australian Work and Life Index (AWALI) Skinner and Pocock found around 55 per cent of employees frequently felt rushed or pressed for time and this was associated with long working hours, work overload and an overall poor work–life interaction (8). These trends have coincided with long-term changes in the type and location of work. In Australia, like many other developed countries, information-based occupations have taken over manufacturing jobs and there has been an increase in part-time and casual work (cf. Watson et al.). Many employees now conduct work outside of the traditional workplace, with the ABS reporting that in 2008, 24 per cent of employees worked at least some hours at home. Many social analysts have explained the rise of casual and flexible labour as related to the transition to global capitalism driven by the expansion of networked information processes (cf. Castells; Van Dijk). This shift is not simply that more workers are producing ideas and information but that the previously separated spheres of production and consumption have blurred (cf. Ritzer and Jurgenson). With this, entirely new industries have sprung up, predicated on the often unpaid for creative labour of individuals, including users of media technologies. A growing chorus of writers are now pointing out that a fragmented, polarised and complex picture is emerging of this so-called "new economy", with significant implications for the quality of work (cf. Edwards and Wajcman; Fudge and Owens; Huws). Indeed, some claim that new conditions of insecure and poor quality employment or "precarious work" are fast becoming the norm. Moreover, this longer-term pattern runs parallel to the production of a multitude of new mobile media technologies, first taken up by professionals and then by the mainstream, challenging the notion that activities are bound to any particular place or time. Reinvigorating Work in Social and Cultural Analysis There are moves to reposition social and cultural analysis to respond to these various trends. Work-life balance is an example of a research and policy area that has emerged since the 1990s. The boundary between the household and the outside world has also been subject to scrutiny by cultural researchers, and these critically examine the intersection between work and consumption, gender and care (cf. Nippert-Eng; Sorenson and Lie; Noble and Lupton, "Consuming" and "Mine"; Lally). These responses are examples of a shift away from what Urry has dubbed "structures and stable organisations" to a concern with flows, movements and the blurring of boundaries between life spheres (5). In a similar vein, researchers recently have proposed alternative ways to describe the changing times and places of employment. In their study of UK professionals, Felstead, Jewson and Walters proposed a model of "plural workscapes" to explain a major shift in the spatial organisation of work (23). Mobility theorists Sheller and Urry have called for the need to "develop a more dynamic conceptualisation of the fluidities and mobilities that have increasingly hybridised the public and private" (113). All of this literature has reinforced a growing concern that in the face of new patterns of production and consumption and with the rise of complex media environments, traditional models and measures of space and time are inadequate to account for contemporary work. Analyses that rely on conventional measures of work based on hourly units clearly point to an increase in the volume of work, the speed of work and to the collision (cf. Pocock) of work and life but fall down in accounting for the complex and often contradictory role of technology. Media technologies are "Janus-faced" as Michael Arnold has suggested, referring to the two-faced Roman god to foreground the contradictory effects at the centre of all technologies (232). Wajcman notes this paradox in her research on mobile media and time, pointing out that mobile phones are just as likely to "save" time as to "consume" it (15). It was precisely this problematic of the complex interactions of the space, time and technology of work that was at stake in my research on the daily use of ICT by professional workers. In the context of changes to the location, activity and meaning of work, and with the multiplying array of old and new media technologies used by workers, how can the boundary and scope of work be determined? What are the implications of these shifting grounds for the experience and quality of work? Officing: A Material Practices Account of Office Work In the remaining article I introduce some of the key ideas and principles of a material practices account developed in my PhD, Officing: Professionals' Daily ICT Use and the Changing Space and Time of Work. This research took place between 2006 and 2007 focusing in-depth on the daily technology practices of twenty professional workers in a municipal council in Sydney and a unit of a global telecommunication company taking part in a trial of a new smart phone. Officing builds on efforts to develop a more accurate account of the space and time of work bringing into play the complex and highly mediated environment in which work takes place. It extends more recent practice-based, actor-network and cultural approaches that have, for some time, been moving towards a more co-constitutive and process-oriented approach to media and technology in society. Turning first to "bricolage" from the French bricole meaning something small and handmade, bricolage refers to the ways that individuals and groups borrow from existing cultural forms and meanings to create new uses, meanings and identities. Initially proposed by Levi-Strauss and then taken up by de Certeau, bricolage has been a useful concept within subculture and lifestyle studies to reveal the creative work performed on signs and meaning systems in forming cultural identities (cf. O'Sullivan et al.). Bricolage is also an important concept for understanding how meanings and uses are inscribed into forms in use rather than being read or activated off their design. This is the process of appropriation, through which both the object and the person are mutually shaped and users gain a sense of control and ownership (cf. Noble and Lupton; Lally; Silverstone and Haddon). The concept of bricolage highlights the improvisational qualities of appropriation and its status as work. A bricoleur is thus a person who constructs new meanings and forms by drawing on and assembling a wide range of resources at hand, sourced from multiple spheres of life. One of the problems with how bricolage and appropriation has been applied to date, notwithstanding the priority given to the domestic sphere, is the tendency to grant individuals and collectives too much control to stabilise the meanings and purposes of technologies. This problem is evident in the research drawing on the framework of "domestication" (cf. Silverstone and Haddon). In practice, the sheer volume of technologically-related issues encountered on a daily basis and the accompanying sense of frustration indicates there is no inevitable drift towards stability, nor are problems merely aberrational or trivial. Instead, daily limits to agency and attempts to overcome these are points at which meanings as well as uses are re-articulated and potentially re-invented. This is where "articulation work" comes in. Initially put forward by Anselm Strauss in 1985, articulation work has become an established analytical tool for informing technology design processes in such fields as Computer-Supported Cooperative Work (CSCW) and Workplace Studies. In these, articulation work is narrowly defined to refer to the real time activities of cooperative work. It includes dealing with contingencies, keeping technologies and systems working and making adjustments to accommodate for problems (Suchman "Supporting", 407). In combination with naturalistic investigations, this concept has facilitated engagement with the increasingly complex technological and media environments of work. It has been a powerful tool for highlighting practices deemed unimportant but which are nevertheless crucial for getting work done. Articulation work, however, has the potential to be applied in a broader sense to explain the significance of the instability of technologies and the efforts to overcome these as transformative in themselves, part of the ongoing process of appropriation that goes well beyond individual tasks or technologies. With clear correspondences to actor-network theory, this expanded definition provides the basis for a new understanding of the office as a temporary and provisional condition of stability achieved through the daily creative and improvisational activities of workers. The office, then, is dependent on and inextricably bound up in its ongoing articulation and crucially, is not bound to a particular place or time. In the context of the large-scale transformations in work already discussed, this expanded definition of articulation work helps to; firstly, address how work is re-organised and re-rationalised through changes to the material conditions of work; secondly, identify the ongoing articulations that this entails and thirdly; understand the role of these articulations in the construction of the space and time of work. This expanded definition is achieved in the newly developed concept of officing. Officing describes a form of labour directed towards the production of a stable office platform. Significantly, one of the main characteristics of this work is that it often goes undetected by organisations as well as by the workers that perform it. As explained later, its "invisibility" is in part a function of its embodiment but also relates to the boundless nature of officing, taking place both inside and outside the workplace, in or out of work time. Officing is made up of a set of interwoven activities of three main types: connecting, synchronising and configuring. Connecting can be understood as aligning technical and social relations for the performance of work at a set time. Synchronising brings together and coordinates different times and temporal demands, for example, the time of "work" with "life" or the time "out in the field" with time "in the workplace". Configuring prepares the space of work, making a single technology or media environment work to some planned action or existing pattern of activity. To give an example of connecting: in the Citizens' Service Centre of the Council, Danielle's morning rituals involved a series of connections even before her work of advising customers begins: My day: get in, sit down, turn on the computer and then slowly open each software program that I will need to use…turn on the phone, key in my password, turn on the headphones and sit there and wait for the calls! (Humphry Officing, 123) These connections not only set up and initiate the performance of work but also mark Danielle's presence in her office. Through these activities, which in practice overlap and blur, the space and time of the office comes to appear as a somewhat separate and mostly invisible structure or infrastructure. The work that goes into making the office stable takes place around the boundary of work with implications for how this boundary is constituted. These efforts do not cluster around boundaries in any simple sense but become part of the process of boundary making, contributing to the construction of categories such as "work" and "life". So, for example, for staff in the smart phone trial, the phone had become their main source of information and communication. Turning their smart phone off, or losing connectivity had ramifications that cascaded throughout their lifeworld. On the one hand, this lead to the breakdown of the distinction between "work" and "life" and a sense of "ever-presence", requiring constant and vigilant "boundary work" (cf. Nippert-Eng). On the other hand, this same state also enabled workers to respond to demands in their own time and across multiple boundaries, giving workers a sense of flexibility, control and of being "in sync". Connecting, configuring and synchronising are activities performed by bodies, producing an embodied transformation. In the tradition of phenomenology, most notably in the works of Heidegger, Merleau-Ponty and more recently Ihde, embodiment is used to explain the relationship between subjects and objects. This concept has since been developed to be understood as not residing in the body but as spread through social, material and discursive arrangements (cf. Haraway, "Situated" and Simians; Henke; Suchman, "Figuring"). Tracing efforts towards making the office stable is thus a way of uncovering how the body, as a constitutive part of a larger arrangement or network, is formed through embodiment, how it gains its competencies, social meanings and ultimately, how workers gain a sense of what it means to be a professional. So, in the smart phone trial, staff managed their connections by replying immediately to their voice, text and data messages. This immediacy not only acted as proof of their presence in the office. It also signalled their commitment to their office: their active participation and value to the organisation and their readiness to perform when called on. Importantly, this embodied transformation also helps to explain how officing becomes an example of "invisible work" (cf. Star and Strauss). Acts of connecting, synchronising and configuring become constituted and forgotten in and through bodies, spaces and times. Through their repeated performance these acts become habits, a transparent means through which the environment of work is navigated in the form of skills and techniques, configurations and routines. In conclusion, researching work in contemporary societies means confronting its marginalisation within cultural research and developing ways to comprehend and measure the interaction of space, time and the ever-multiplying array of media technologies. Officing provides a way to do this by shifting to an understanding of the workplace as a contingent product of work itself. The strength of this approach is that it highlights the creative and ongoing work of individuals on their media infrastructures. It also helps to identify and describe work activities that are not neatly contained in a workplace, thus adding to their invisibility. The invisibility of these practices can have significant impacts on workers: magnifying feelings of time pressure and a need to work faster, longer and harder even as discrete technologies are utilised to save time. In this way, officing exposes some of the additional contributions to the changing experience and quality of work as well as to the construction of everyday domains. Officing supports an evaluation of claims of productivity and work-life balance in relation to new media technologies. In the smart phone trial, contrary to an assumed increase in productivity, mobility of work was achieved at the expense of productivity. Making the mobile office stable—getting it up and running, keeping it working in changing environments and meeting expectations of speed and connectivity—took up time, resulting in an overall productivity loss and demanding more "boundary work". In spite of their adaptability and flexibility, staff tended to overwork to counteract this loss. This represented a major shift in the burden of effort in the production of office forms away from the organisation and towards the individual. Finally, though not addressed here in any detail, officing could conceivably have practical uses for designing more sustainable office environments that better support the work process and the balance of work and life. Thus, by accounting more accurately for the resource requirements of work, organisations can reduce the daily effort, space and time taken up by employees on their work environments. In any case, what is clear, is the ongoing need to continue a cultural research agenda on work—to address the connections between transformations in work and the myriad material practices that individuals perform in going about their daily work. References Arnold, Michael. "On the Phenomenology of Technology: The 'Janus-Faces' of Mobile Phones." Information and Organization 13.4 (2003): 231–56. Australian Bureau of Statistics. 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“What's the brief?” is an everyday question within the graphic design process. Moreover, the concept and importance of a design brief is overtly understood well beyond design practice itself—especially among stakeholders who work with designers and clients who commission design services. Indeed, a design brief is often an assumed and expected physical or metaphoric artefact for guiding the creative process. When a brief is lacking, incomplete or unclear, it can render an already ambiguous graphic design process and discipline even more fraught with misinterpretation. Nevertheless, even in wider design discourse, there appears to be little research on design briefs and the briefing process (Jones and Askland; Paton and Dorst). It seems astonishing that, even in Peter Phillips’s 2014 edition of Creating the Perfect Design Brief, he feels compelled to comment that “there are still no books available about design briefs” and that the topic is only “vaguely” covered within design education (21). While Phillips’s assertion is debatable if one draws purely from online vernacular sources or professional guides, it is supported by the lack of scholarly attention paid to the design brief. Graphic design briefs are often mentioned within design books, journals, and online sources. However, this article argues that the format, function and use of such briefs are largely assumed and rarely identified and studied. Even within the broader field of design research, the tendency appears to be to default to “the design brief” as an assumed shorthand, supporting Phillips’s argument about the nebulous nature of the topic. As this article contextualises, this is further problematised by insufficient attention cast on graphic design itself as a specific discipline. This article emerges from a wider, multi-stage creative practice study into graphic design practice, that used experimental performative design research methods to investigate graphic designers’ professional relationships with stakeholders (Meron, Strangely). The article engages with specific outcomes from that study that relate to the design brief. The article also explores existing literature and research and argues for academics, the design industry, and educationalists, to focus closer attention on the design brief. It concludes by suggesting that experimental and collaborative design methods offers potential for future research into the design brief. Contextualising the Design Brief It is critical to differentiate the graphic design brief from the operational briefs of architectural design (Blyth and Worthington; Khan) or those used in technical practices such as software development or IT systems design, which have extensive industry-formalised briefing practices and models such as the waterfall system (Petersen et al.) or more modern processes such as Agile (Martin). Software development and other technical design briefs are necessarily more formulaically structured than graphic design briefs. Their requirements are generally empirically and mechanistically located, and often mission-critical. In contrast, the conceptual nature of creative briefs in graphic design creates the potential for them to be arbitrarily interpreted. Even in wider design discourse, there appears to be little consistency about the form that a brief takes. Some sources indicate that a brief only requires one page (Elebute; Nov and Jones) or even a single line of text (Jones and Askland). At other times briefs are described as complex, high-level documents embedded within processes which designers respond to with the aim of producing end products to satisfy clients’ requirements (Ambrose; Patterson and Saville). Ashby and Johnson (40) refer to the design brief as a “solution neutral” statement, the aim being to avoid preconceptions or the narrowing of the creative possibilities of a project. Others describe a consultative (Walsh), collaborative and stakeholder-inclusive process (Phillips). The Scholarly Brief Within scholarly design research, briefs inevitably manifest as an assumed artefact or process within each project; but the reason for their use or antecedents for chosen formats are rarely addressed. For example, in “Creativity in the Design Process” (Dorst and Cross) some elements of the design brief are described. The authors also describe at what stage of the investigation the brief is introduced and present a partial example of the brief. However, there is no explanation of the form of the brief or the reasons behind it. They simply describe it as being typical for the design medium, adding that its use was considered a critical part of addressing the design problem. In a separate study within advertising (Johar et al.), researchers even admit that the omission of crucial elements from the brief—normally present in professional practice—had a detrimental effect on their results. Such examples indicate the importance of briefs for the design process, yet further illustrating the omission of direct engagement with the brief within the research design, methodology, and methods. One exception comes from a study amongst business students (Sadowska and Laffy) that used the design brief as a pedagogical tool and indicates that interaction with, and changes to, elements of a design brief impact the overall learning process of participants, with the brief functioning as a trigger for that process. Such acknowledgement of the agency of a design brief affirms its importance for professional designers (Koslow et al.; Phillips). This use of a brief as a research device informed my use of it as a reflective and motivational conduit when studying graphic designers’ perceptions of stakeholders, and this will be discussed shortly. The Professional Brief Professionally, the brief is a key method of communication between designers and stakeholders, serving numerous functions including: outlining creative requirements, audience, and project scope; confirming project requirements; and assigning and documenting roles, procedures, methods, and approval processes. The format of design briefs varies from complex multi-page procedural documents (Patterson and Saville; Ambrose) produced by marketing departments and sent to graphic design agencies, to simple statements (Jones and Askland; Elebute) from small to medium-sized businesses. These can be described as the initial proposition of the design brief, with the following interactions comprising the ongoing briefing process. However, research points to many concerns about the lack of adequate briefing information (Koslow, Sasser and Riordan). It has been noted (Murray) that, despite its centrality to graphic design, the briefing process rarely lives up to designers’ expectations or requirements, with the approach itself often haphazard. This reinforces the necessarily adaptive, flexible, and compromise-requiring nature of professional graphic design practice, referred to by design researchers (Cross; Paton and Dorst). However, rather than lauding these adaptive and flexible designer abilities as design attributes, such traits are often perceived by professional practitioners as unequal (Benson and Dresdow), having evolved by the imposition by stakeholders, rather than being embraced by graphic designers as positive designer skill-sets. The Indeterminate Brief With insufficient attention cast on graphic design as a specific scholarly discipline (Walker; Jacobs; Heller, Education), there is even less research on the briefing process within graphic design practice (Cumming). Literature from professional practice on the creation and function of graphic design briefs is often formulaic (Phillips) and fractured. It spans professional design bodies, to templates from mass-market printers (Kwik Kopy), to marketing-driven and brand-development approaches, in-house style guides, and instructional YouTube videos (David). A particularly clear summary comes from Britain’s Design Council. This example describes the importance of a good design brief, its requirements, and carries a broad checklist that includes the company background, project aims, and target audience. It even includes stylistic tips such as “don’t be afraid to use emotive language in a brief if you think it will generate a shared passion about the project” (Design Council). From a subjective perspective, these sources appear to contain sensible professional advice. However, with little scholarly research on the topic, how can we know that, for example, using emotive language best informs the design process? Why might this be helpful and desirable (or otherwise) for designers? These varied approaches highlight the indeterminate treatment of the design brief. Nevertheless, the very existence of such diverse methods communicates a pattern of acknowledgement of the criticality of the brief, as well as the desire, by professional bodies, commentators, and suppliers, to ensure that both designers and stakeholders engage effectively with the briefing process. Thus, with such a pedagogic gap in graphic design discourse, scholarly research into the design brief has the potential to inform vernacular and formal educational resources. Researching the Design Brief The research study from which this article emerges (Meron, Strangely) yielded outcomes from face-to-face interviews with eleven (deidentified) graphic designers about their perceptions of design practice, with particular regard to their professional relationships with other creative stakeholders. The study also surveyed online discussions from graphic design forums and blog posts. This first stage of research uncovered feelings of lacking organisational gravitas, creative ownership, professional confidence, and design legitimacy among the designers in relation to stakeholders. A significant causal factor pointed to practitioners’ perceptions of lacking direct access to and involvement with key sources of creative inspiration and information; one specific area being the design brief. It was a discovery that was reproduced thematically during the second stage of the research. This stage repurposed performative design research methods to intervene in graphic designers’ resistance to research (Roberts, et al), with the goal of bypassing practitioners’ tendency to portray their everyday practices using formulaic professionalised answers (Dorland, View). In aiming to understand graphic designers’ underlying motivations, this method replaced the graphic designer participants with trained actors, who re-performed narratives from the online discussions and designer interviews during a series of performance workshops. Performative methodologies were used as design thinking methods to defamiliarise the graphic design process, thereby enabling previously unacknowledged aspects of the design process to be unveiled, identified and analysed. Such defamiliarisation repurposes methods used in creative practice, including design thinking (Bell, Blythe, and Sengers), with performative elements drawing on ethnography (Eisner) and experimental design (Seago and Dunne). Binding these two stages of research study together was a Performative Design Brief—a physical document combining narratives from the online discussions and the designer interviews. For the second stage, this brief was given to a professional theatre director to use as material for a “script” to motivate the actors. In addition to identifying unequal access to the creative process as a potential point of friction, this study yielded outcomes suggesting that designers were especially frustrated when the design brief was unclear, insufficiently detailed, or even missing completely. The performative methodology enabled a refractive approach, using performative metaphor and theatre to defamiliarise graphic design practice, portraying the process through a third-party theatrical prism. This intervened in graphic designers’ habitual communication patterns (Dorland, The View). Thus, combining traditional design research methods with experimental interdisciplinary ones, enabled outcomes that might not otherwise have emerged. It is an example of engaging with the fluid, hybrid (Heller, Teaching), and often elusive practices (van der Waarde) of graphic design. Format, Function, and Use A study (Paton and Dorst) among professional graphic designers attempts to dissect practitioners’ perceptions of different aspects of briefing as a process of ‘framing’. Building on the broader theories of design researchers such as Nigel Cross, Bryan Lawson, and Donald Schön, Paton and Dorst suggest that most of the designers preferred a collaborative briefing process where both they and client stakeholders were directly involved, without intermediaries. This concurs with the desire, from many graphic designers that I interviewed, for unobstructed engagement with the brief. Moreover, narratives from the online discussions that I investigated suggest that the lack of clear frameworks for graphic design briefs is a hotly debated topic, as are perceptions of stakeholder belligerence or misunderstanding. For example, in a discussion from Graphic Design Forums designer experiences range from only ever receiving informal verbal instructions—“basically, we’ve been handed design work and they tell us ‘We need this by EOD’” (VFernandes)—to feeling obliged to pressure stakeholders to provide a brief—“put the burden on them to flesh out the details of a real brief and provide comprehensive material input” (HotButton) —to resignation to an apparent futility of gaining adequate design briefs from stakeholders because— “they will most likely never change” (KitchWitch). Such negative assumptions support Koslow et al.’s assertion that the absence of a comprehensive brief is the most “terrifying” thing for practitioners (9). Thus, practitioners’ frustrations with stakeholders can become unproductive when there is an inadequate design brief, or if the creative requirements of a brief are otherwise removed from the direct orbit of graphic designers. This further informs a narrative of graphic designers perceiving some stakeholders as gatekeepers of the design brief. For example, one interviewed designer believed that stakeholders ‘don’t really understand the process’ (Patricia). Another interviewee suggested that disorganised briefs could be avoided by involving designers early in the process, ensuring that practitioners had direct access to the client as a creative source, rather than having to circumnavigate stakeholders (Marcus). Such perceptions appeared to reinforce beliefs among these practitioners that they lack design capital within the creative process. These perceptions of gatekeeping of the design brief support suggestions of designers responding negatively when stakeholders approach the design process from a different perspective (Wall and Callister), if stakeholders assume a managerial position (Jacobs) and, in particular, if stakeholders are inexperienced in working with designers (Banks et al.; Holzmann and Golan). With such little clarity in the design briefing process, future research may consider comparisons with industries with more formalised briefing processes, established professional statuses, or more linear histories. Indeed, the uneven historical development of graphic design (Frascara; Julier and Narotzky) may influence the inconsistency of its briefing process. Inconsistency as Research Opportunity The inconsistent state of the graphic design brief is reflective of the broader profession that it resides within. Graphic design as a profession remains fluid and inconsistent (Dorland, Tell Me; Jacobs), with even its own practitioners unable to agree on its parameters or even what to call the practice (Meron, Terminology). Pedagogically, graphic design is still emerging as an independent discipline (Cabianca; Davis), struggling to gain capital outside of existing and broader creative practices (Poynor; Triggs). The inherent interdisciplinarity (Harland) and intangibility of graphic design also impact the difficulty of engaging with the briefing process. Indeed, graphic design’s practices have been described as “somewhere between science and superstition (or fact and anecdote)” (Heller, Teaching par. 3). With such obstacles rendering the discipline fractured (Ambrose et al.), it is understandable that stakeholders might find engaging productively with graphic design briefs challenging. This can become problematic, with inadequate stakeholder affinity or understanding of design issues potentially leading to creative discord (Banks et al.; Holzmann and Golan). Identifying potentially problematic and haphazard aspects of the design brief and process also presents opportunities to add value to research into broader relationships between graphic designers and stakeholders. It suggests a practical area of study with which scholarly research on collaborative design approaches might intersect with professional graphic design practice. Indeed, recent research suggests that collaborative approaches offer both process and educational advantages, particularly in the area of persona development, having the ability to discover the “real” brief (Taffe 394). Thus, framing the brief as a collaborative, educative, and negotiative process may allow creative professionals to elucidate and manage the disparate parts of a design process, such as timeframes, stakeholders, and task responsibilities, as well as the cost implications of stakeholder actions such as unscheduled amendments. It can encourage the formalisation of incomplete vernacular briefs, as well as allow for the influence of diverse briefing methods, such as the one-page creative brief of advertising agencies, or more formal project management practices while allowing for some of the fluidity of more agile approaches: acknowledging that changes may be required while keeping all parties informed and involved. In turn, collaborative approaches may contribute towards enabling the value of contributions from both graphic designers and stakeholders and it seems beneficial to look towards design research methodologies that promote collaborative pathways. Mark Steen, for example, argues for co-design as a form of design thinking for enabling stakeholders to combine knowledge with negotiation to implement change (27). Collaborative design methods have also been advocated for use between designers and users, with stakeholders on shared projects, and with external collaborators (Binder and Brandt). Others have argued that co-design methods facilitate stakeholder collaboration “across and within institutional structures” while challenging existing power relations, albeit leaving structural changes largely unaffected (Farr 637). The challenge for collaborative design research is to seek opportunities and methodologies to conduct design brief research within a graphic design process that often appears amorphous, while also manifesting complex designer–stakeholder dynamics. Doubly so, when the research focus—the graphic design brief—often appears as nebulous an entity as the practice it emerges from. Conclusion The research discussed in this article suggests that graphic designers distrust a creative process that itself symbolises an inconsistent, reactive, and often accidental historical development of their profession and pedagogy. Reflecting this, the graphic design brief emerges almost as a metaphor for this process. The lack of overt discussion about the format, scope, and process of the brief feeds into the wider framework of graphic design’s struggle to become an independent scholarly discipline. This, in turn, potentially undermines the professional authority of graphic design practice that some of its practitioners believe is deficient. Ultimately, the brief and its processes must become research-informed parts of graphic design pedagogy. Embracing the brief as a pedagogical, generative, and inseparable part of the design process can inform the discourse within education, adding scholarly value to practice and potentially resulting in increased agency for practitioners. The chameleon-like nature of graphic design’s constant adaptation to ever-changing industry requirements makes research into the role and influences of its briefing process challenging. Thus, it also follows that the graphic design brief is unlikely to quickly become as formalised a document or process as those from other disciplines. But these are challenges that scholars and professionals must surely embrace if pedagogy is to gain the research evidence to influence practice. As this article argues, the often obfuscated practices and inherent interdisciplinarity of graphic design benefit from experimental research methods, while graphic designers appear responsive to inclusive approaches. Thus, performative methods appear effective as tools of discovery and collaborative methodologies offer hope for organisational intervention. References Ambrose, Gavin. Design Thinking for Visual Communication. Fairchild, 2015. Ambrose, Gavin, Paul Harris, and Nigel Ball. The Fundamentals of Graphic Design. Bloomsbury, 2020. Ashby, M.F., and Kara Johnson. Materials and Design: The Art and Science of Material Selection in Product Design. Elsevier Butterworth-Heinemann, 2010. 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 For once I want to be the car crash, Not always just the traffic jam. Hit me hard enough to wake me, And lead me wild to your dark roads. (Snow Patrol: “Headlights on Dark Roads”, Eyes Open, 2006) I didn’t know about the online dating site rsvp.com.au until a woman who I was dating at the time showed me her online profile. Apparently ‘everyone does rsvp’. Well, ‘everyone’ except me. (Before things ended I never did ask her why she listed herself as ‘single’ on her profile…) Forming relationships in our era of post-institutional modes of sociality is problematic. Some probably find such ‘romantically’ orientated ‘meet up’ sites to be a more efficient option for sampling what is available. Perhaps others want some loving on the side. In some ways these sites transform romance into the online equivalent of the logistics dock at your local shopping centre. ‘Just-in-time’ relationships rely less on social support structures of traditional institutions such as the family, workplace, and so on, including ‘love’ itself, and more on a hit and miss style of dating, organised like a series of car crashes and perhaps even commodified through an eBay-style online catalogue (see Crawford 83-88). Instead of image-commodities there are image-people and the spectacle of post-romance romance as a debauched demolition derby. Is romance still possible if it is no longer the naïve and fatalistic realisation of complementary souls? I watched Paul Thomas Anderson’s third film Punch-Drunk Love with the above rsvp.com.au woman. She interpreted it in a completely different manner to me. I shall argue (as I did with her) that the film captures some sense of romance in a post-romance world. The film was billed as a comedy/romance or comedy/drama, but I did not laugh either with or at the film. The story covers the trials of two people ‘falling in love’. Lena Leonard (Emma Watson) orchestrates an encounter with Barry Egan (Adam Sandler) after seeing a picture of him with his seven sisters. The trajectory of the romance is defined less by the meeting of two people, than the violence of contingency and of the world arrayed by the event of love. Contingency is central to complexity theory. Contingency is not pure chance, rather it exists as part of the processual material time of the event that defines events or a series of events as problematic (Deleuze, The Logic of Sense 52-53). To problematise events and recognise the contingencies they inculcate is to refuse the tendency to colonise the future through actuarial practices, such as ‘risk management’ and insurance or the probabilistic ‘Perfect Match’ success of internet dating sites (mirroring ‘Dexter’ from the 1980s dating television game show). Therefore, through Punch-Drunk Love I shall problematise the event of love so as to resuscitate the contingencies of post-romance romance. It is not surprising Punch-Drunk Love opens with a car crash for the film takes romance on a veritable post-Crash detour. Crash – novel and film – serves as an exploration of surfaces and desire in a world at the intersection of the accident. Jean Baudrillard, in his infamous essay on Crash (novel), dwells on the repositioning of the accident: [It] is no longer at the margin, it is at the heart. It is no longer the exception to a triumphal rationality, it has become the Rule, it has devoured the Rule. … Everything is reversed. It is the Accident that gives form to life, it is the Accident, the insane, that is the sex of life. (113) After the SUV rolls over in Punch-Drunk Love’s opening scene, a taxi van pauses long enough for an occupant to drop off a harmonium. A harmonium is a cross between an organ and a piano, but much smaller than both. It is a harmony machine. It breathes and wheezes to gather potentiality consonant sound waves of heterogeneous frequencies to produce a unique musicality of multiplicative resonance. No reason is given for the harmonium in the workings of the film’s plot. Another accident without any explanation, like the SUV crash, but this time it is an accidental harmony-machine. The SUV accident is a disorganising eruption of excess force, while the accidental harmony-machine is a synthesising organisation of force. One produces abolition, while the other produces a multiplicative affirmation. These are two tendencies that follow two different relations to the heterogeneous materialism of contingency. Punch-Drunk Love captures the contingency at the heart of post-romance romance. Instead of the layers of expectation habituated into institutional engagements of two subjects meeting, there is the accident of the event of love within which various parties are arrayed with various affects and desires. I shall follow Alain Badiou’s definition of the event of love, but only to the point where I shall shift the perspective from love to romance. Badiou defines love by initially offering a series of negative definitions. Firstly, love is not a fusional concept, the ‘two’ that is ‘one’. That is because, as Badiou writes, “an ecstatic One can only be supposed beyond the Two as a suppression of the multiple” (“What Is Love?” 38). Secondly, nor is love the “prostration of the Same on the alter of the Other.” Badiou argues that it is not an experience of the Other, but an “experience of the world [i.e. multiple], or of the situation, under the post-evental condition that there were Two” (“What Is Love?” 39). Lastly, the rejection of the ‘superstructural’ or illusory conception of love, that is, to the base of desire and sexual jealously (Badiou, “What Is Love?” 39). For Badiou love is the production of truth. The truth is that the Two, and not only the One, are at work in the situation. However, from the perspective of romance, there is no post-evental truth procedure for love as such. In Deleuze’s terminology, from the perspective of post-romance the Two serves an important role as the ‘quasi-cause’ of love (The Logic of Sense 33), or for Badiou it is the “noemenal possibility [virtualite]” (“What Is Love?” 51). The event of the Two, and, therefore, of love, is immanent to itself. However, this does not capture the romantic functioning of love swept up in the quasi-cause of the Two. Romance is the differential repetition of the event of love to-come and thus the repetition of the intrinsic irreducible wonder at the heart of the event. The wonder at love’s heart is the excess of potentiality, the excitement, the multiplicity, the stultifying surprise. To resuscitate the functioning of love is to disagree with Badiou’s axiom that there is an absolute disjunction between the (nominalist) Two. The Two do actually share a common dimension and that is the radical contingency at the heart of love. Love is not as a teleological destiny of the eternal quasi-cause, but the fantastic impossibility of its contingent evental site. From Badiou’s line of argument, romance is precisely the passage of this “aleatory enquiry” (“What is Love?” 45), of “the world from the point of view of the Two, and not an enquiry of each term of the Two about the other” (49). Romance is the insinuation of desire into this dynamic of enquiry. Therefore, the functioning of romance is to produce a virtual architecture of wonder hewn from seeming impossibility of contingency. It is not the contingency in itself that is impossible (the ‘chaosmos’ is a manifold of wonderless-contingency), but that contingency might be repeated as part of a material practice that produces love as an effect of differentiating wonder. Or, again, not that the encounter of love has happened, but that precisely it might happen again and again. Romance is the material and embodied practice of producing wonder. The materiality of romance needs to be properly outlined and to do this I turn to another of Badiou’s texts and the film itself. To explicate the materialism of romance is to begin outlining the problematic of romance where the material force of Lena and Barry’s harmony resonates in the virtuosic co-production of new potentialities. The practice of romance is evidenced in the scene where Lena and Barry are in Hawaii and Lena is speaking to Barry’s sister while Barry is watching her. A sense of wonder is produced not in the other person but of the world as multiplicity produced free from the burden of Barry’s sister, hence altering the material conditions of the differential repetition of contingency. The materialism in effect here is, to borrow from Michel Foucault, an ‘incorporeal materialism’ (169), and pertains to the virtual evental dimension of love. In his Handbook of Inaesthetics, Badiou sets up dance and theatre as metaphors for thought. “The essence of dance,” writes Badiou, “is virtual, rather than actual movement” (Handbook of Inaesthetics 61), while theatre is an “assemblage” (72) which in part is “the circulation of desire between the sexes” (71). If romance is the deliberate care for the event of love and its (im)possible contingency, then the dance of love requires the theatre of romance. To include music with dance is to malign Badiou’s conception of dance by polluting it with some elements of what he calls ‘theatre’. To return to the Hawaii scene, Barry is arrayed as an example of what Badiou calls the ‘public’ of theatre because he is watching Lena lie to his sister about his whereabouts, and therefore completes the ‘idea’ of theatre-romance as a constituent element (Badiou, Handbook of Inaesthetics 74). There is an incorporeal (virtual) movement here of pure love in the theatre of romance that repotentialises the conditions of the event of love by producing a repeated and yet different contingency of the world. Wonder triggered by a lie manifest of a truth to-come. According to Badiou, the history of dance is “governed by the perpetual renewal of the relation between vertigo and exactitude. What will remain virtual, what will be actualized, and precisely how is the restraint going to free the infinite?” (Handbook of Inaesthetics 70). Importantly, Badiou suggests that theatrical production “is often the reasoned trial of chances” (Handbook of Inaesthetics 74). Another way to think the materiality of romance is as the event of love, but without Badiou’s necessary declaration of love (“What Is Love?” 45). Even though the ‘truth’ of the Two acts as quasi-cause, love as such remains a pure (‘incorporeal’) Virtuality. As a process, there is no “absolute disappearance or eclipse” that belongs to the love-encounter (“What Is Love?” 45), thus instead producing a rhythmic or, better, melodic heterogeneous tension between the love-dance and romance-theatre. The rhythm-melody of the virtual-actual cascade is distributed around aleatory contingencies as the event of love is differentially repeated and is therefore continually repotentialised and exhausted at the same time. A careful or graceful balance needs to be found between potentiality and exhaustion. The film contains many examples of this (re)potentialising tension, including when Lena achieves the wonder of the ‘encounter’ by orchestrating a meeting. Similarly, Barry feigns a ‘business trip’ to Hawaii to meet up with Lena. This is proceeded by the increased urgency of Barry’s manipulation of the frequent flyer miles reward to meet with up with Lena. The tension is affective – both anxious and exciting – and belongs to the lived duration of contingency. In the same way as an actual material dance floor (or ‘theatre’ here) is repeated across multiple incorporeal dimensions of music’s virtuality through the repotentialisation of the dancer’s body, the multiple dimensions of love are repeated across the virtuality of the lovers’ actions through the repotentialisation of the conditions of the event of love. Punch-Drunk Love frames this problematic of romance by way of a second movement that follows the trajectory of the main character Barry. Barry is a depressive with an affect regulation problem. He flies into a rage whenever a childhood incident is mentioned and becomes anxious or ‘scared’ (as one sister described him) when in proximity to Lena. He tries to escape from the oppressive intimacy of his family. He plays with ‘identity’ in a childlike manner by dressing up as a businessman and wearing the blue suit. His small business is organised around selling plungers used to unblock toilets to produce flow. Indeed, Barry is defined by the blockages and flows of desire. His seven-sister over-Oedipalised familial unit continually operates as an apparatus of capture, a phone-sex pervert scam seeks to overcode desire in libidinal economy that becomes exploited in circuits of axiomatised shame (like an online dating site?), and a consumer rewards program that offers the dream of a frequent-flyer million-miles (line of) flight out of it all. ‘Oedipal’ in the expanded sense Deleuze and Guattari give the term as a “displaced or internalised limit where desire lets itself be caught. The Oedipal triangle is the personal and private territoriality that corresponds to all of capitalism’s efforts at social reterritorialisation” (266). Barry says he wants to ‘diversify’ his business, which is not the same thing as ‘expanding’ or developing an already established commercial interest. He does not have a clear idea of what domain or type of business he wants to enter into when diversifying. When he speaks to business contacts or service personnel on the phone he attempts to connect with them on a level of intimacy that is uncomfortably inappropriate for impersonal phone conversations. The inappropriate intimacy comes back to haunt him, of course, when a low-level crook attempts to extort money from him after Barry calls a phone sex line. The romance between Lena and Barry develops through a series of accident-contingencies that to a certain extent ‘unblocks’ Barry and allows him to connect with Lena (who also changes). Apparent contingencies that are not actually contingencies need to be explained as such (‘dropping car off’, ‘beat up bathrooms’, ‘no actual business in Hawaii’, ‘phone sex line’, etc.). Upon their first proper conversation a forklift in Barry’s business crashes into boxes. Barry calls the phone sex line randomly and this leads to the severe car crash towards the end of the film. The interference of Barry’s sisters occurs in an apparently random unexpected manner – either directly or indirectly through the retelling of the ‘gayboy’ story. Lastly, the climatic meeting in Hawaii where the two soon-to-be-lovers are framed by silhouette, their bodies meet not in an embrace but a collision. They emerge as if emitted from the throngs of the passing crowd. Barry has his hand extended as if they were going to shake and there is an audible grunt when their bodies collide in an embrace. To love is to endure the violence of a creative temporality, such as the production of harmony from heterogeneity. As Badiou argues, love cannot be a fusional relation between the two to make the one, nor can it be the relation of the Same to the Other, this is because the differential repetition of the conditions of love through the material practice of romance already effaces such distinctions. This is the crux of the matter: The maximum violence in the plot of Punch-Drunk Love is not born by Lena, even though she ends up in hospital, but by Barry. (Is this merely a masculinist reading of traditional male on male violence? Maybe, and perhaps why rsvp.com.au woman read it different to me.) What I am trying to get at is the positive or creative violence of the two movements within the plot – of the romance and of Barry’s depressive social incompetence – intersect in such a way to force Barry to renew himself as himself. Barry’s explosive fury belongs to the paradox of trying to ‘mind his own business’ while at the same time ‘diversifying’. The moments of violence directed against the world and the ‘glass enclosures’ of his subjectivity are transversal actualisations of the violence of love (on function of ‘glass’ in the film see King). (This raises the question, perhaps irrelevant, regarding the scale of Badiou’s conception of truth-events. After Foucault and Deleuze, why isn’t ‘life’ itself a ‘truth’ event (for Badiou’s position see Briefings on Existence 66-68)? For example, are not the singularities of Barry’s life also the singularities of the event of love? Is the post-evental ‘decision’ supposed to always axiomatically subtract the singular truth-supplement from the stream of singularities of life? Why…?) The violence of love is given literal expression in the film in the ‘pillow talk’ dialogue between Barry and Lena: Barry: I’m sorry, I forgot to shave. Lena: Your face is so adorable. Your skin and your cheek… I want to bite it. I want to bite on your cheek and chew on it, you’re so fucking cute. Barry: I’m looking at your face and I just wanna smash it. I just wanna fucking smash it with a sledgehammer and squeeze you, you’re so pretty… Lena: I wanna chew your face off and scoop out your eyes. I wanna eat them and chew them and suck on them… Barry: [nodding] Ok…yes, that’s funny… Lena: Yeah… Barry: [still nodding] This’s nice. What dismayed or perhaps intrigued Baudrillard about Crash was its mixing of bodies and technologies in a kind of violent eroticism where “everything becomes a hole to offer itself to the discharge reflex” (112). On the surface this exchange between Barry and Lena is apparently an example of such violent eroticism. For Baudrillard the accident is a product of the violence of technology in the logistics of bodies and signs which intervene in relations in such a way to render perversity impossible (as a threshold structuration of the Symbolic) because ‘everything’ becomes perverse. However, writer and director of Punch-Drunk Love, Paul Anderson, produces a sense of the wondrous (‘Punch-Drunk’) violence that is at the heart of love. This is not because of the actual violence of individual characters; in the film this only serves as a canvas of action to illustrate the intrinsic violence of contingency. Lena and Barry’s ‘pillow talk’ not so much as a dance but a case of the necessary theatre capturing the violence and restraint of love’s virtual dance. ‘Violence’ (in the sense it is used above) also describes the harmonic marshalling of the heterogeneous materiality of sound affected by the harmonium. The ‘violence’ of the harmonium is decisively expressed through the coalescence of the diegetic and nondiegetic soundtracks at the end of the film when Barry plays the harmonium concurrently with Jon Brion’s score for the film. King notes, the “diegetic and nondiegetic music playing together is a moment of cinematic harmony; Barry, Lena, and the harmonium are now in sync” (par. 19). The notes of music connect different diegetic and nondiegetic series which pivot around new possibilities. As Deleuze writes about the notes played at a concert, they are “pure Virtualities that are actualized in the origins [of playing], but also pure Possibilities that are attained in vibrations or flux [of sound]” (The Fold 91). Following Deleuze further (The Fold 146-157), the horizontal melodic movement of romance forms a diagonal or transversal line with the differentially repeated ‘harmonic’ higher unity of love. The unity is literally ‘higher’ to the extent it escapes the diegetic confines of the film itself. For Deleuze “harmonic unity is not that of infinity, but that which allows the existent to be thought of as deriving from infinity” (The Fold 147, ital. added). While Barry is playing the harmonium in this scene Lena announces, “So here we go.” These are the final words of the film. In Badiou’s philosophy this is a declaration of the truth of love. Like the ‘higher’ non/diegetic harmony of the harmonium, the truth of love “composes, compounds itself to infinity. It is thus never presented integrally. All knowledge [of romance] relative to this truth [of the Two, as quasi-cause] thus disposes itself as an anticipation” (“What is Love?” 49). Romance is therefore lived as a vertiginous state of anticipation of love’s harmony. The materiality of romance does not simply consist of two people coming together and falling in love. The ‘fall’ functions as a fatalistic myth used to inscribe bodies within the eschatological libidinal economies of ‘romantic comedies’. To anneal Baudrillard’s lament, perversity obviously still has a positive Symbolic function on the internet, especially online dating sites where anticipation can be modulated through the probabilistic manipulation of signs. In post-romance, the ‘encounter’ of love necessarily remains, but it is the contingency of this encounter that matters. The main characters in Punch-Drunk Love are continually arrayed through the contingencies of love. I have linked this to Badiou’s notion of the event of love, but have focused on what I have called the materiality of romance. The materiality of romance requires more than a ‘fall’ induced by a probabilistic encounter, and yet it is not the declaration of a truth. The post-evental truth procedure of love is impossible in post-romance romance because there is no ‘after’ or ‘supplement’ to an event of love; there is only the continual rhythm of romance and anticipation of the impossible. It is not a coincidence that the Snow Patrol lyrics that serve above as an epigraph resonate with Deleuze’s comment that a change in the situation of Leibnizian monads has occurred “between the former model, the closed chapel with imperceptible openings… [to] the new model invoked by Tony Smith [of] the sealed car speeding down the dark highway” (The Fold 157). Post-Crash post-romance romance unfolds like the driving-monad in an aleatory pursuit of accidents. That is, to care for the event of love is not to announce the truth of the Two, but to pursue the differential repetition of the conditions of love’s (im)possible contingency. This exquisite and beautiful care is required for the contingency of love to be maintained. Hence, the post-romance problematic of romance thus posited as the material practice of repeating the wonder at the heart of love. References Badiou, Alain. Briefings on Existence: A Short Treatise on Transitory Ontology. Trans. Norman Madrasz. Albany, New York: State U of New York P, 2006. ———. Handbook of Inaesthetics. Trans. Alberto Toscano. Stanford, Calif.: Stanford UP, 2005. ———. “What Is Love?” Umbr(a) 1 (1996): 37-53. Baudrillard, Jean. Simulacra and Simulation. Ann Arbor: U of Michigan P, 1994. Crawford, Kate. Adult Themes: Rewriting the Rules of Adulthood. Sydney: Macmillan, 2006. Deleuze, Gilles. The Fold: Leibniz and the Baroque. Minneapolis: U of Minnesota P, 1993. ———. The Logic of Sense. Trans. Mark Laster and Charles Stivale. European Perspectives. Ed. Constantin V. Boundas. New York: Columbia UP, 1990. Deleuze, Gilles, and Félix Guattari. Anti-Oedipus: Capitalism and Schizophrenia. Minneapolis: U of Minnesota P, 1983. Foucault, Michel. “Theatricum Philosophicum.” Language, Counter-Memory, Practice: Selected Essays and Interviews. Ed. D. F. Bouchard. New York: Cornell UP, 1977. 165-96. King, Cubie. “Punch Drunk Love: The Budding of an Auteur.” Senses of Cinema 35 (2005). 
 
 
 
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