Journal articles on the topic 'Primary communication fluxes'

Flax for oil seed is a crop of increasing popularity, but its cultivation needs technical improvement. Important agronomic traits such as productivity and resistance to stresses are to be regarded as the result of the combined responses of individual organs and their inter-communication. Ultimately, these responses directly reflect the metabolic profile at the cellular level. Above ground, the complexity of the plant phenotype is governed by leaves at different developmental stages, and their ability to synthesise and exchange metabolites. In this study, the metabolic profile of differently-developed leaves was used firstly to discriminate flax leaf developmental stages, and secondly to analyse the allocation of the metabolites within and between leaves. For this purpose, the concentration of 52 metabolites, both primary and specialized, was followed by gas chromatography (GC-) and liquid chromatography coupled to mass spectrometry (LC-MS) in alternate pairs of flax leaves. On the basis of their metabolic content, three populations of leaves in different growth stages could be distinguished. Primary and specialized metabolites showed characteristic distribution patterns, and compounds similarly evolving with leaf age could be grouped by the aid of the Kohonen self-organising map (SOM) algorithm. Ultimately, visualisation of the correlations between metabolites via hierarchical cluster analysis (HCA) allowed the assessment of the metabolic fluxes characterising different leaf developmental stages, and the investigation of the relationships between primary and specialized metabolites.

Exosomes are important intercellular communication vehicles, secreted into body fluids by multiple cell types, including tumor cells. They contribute to the metastatic progression of tumor cells through paracrine signalling. It has been recently discovered that blood circulating exosomes contain distinguishable fractions of free and cell-surface-associated vesicles. We evaluated the influence of protein cargoes from exosomes from plasma, and exosomes from the total blood of healthy females (HFs) and breast cancer patients (BCPs), on cell motility. We conducted a mass spectrometric analysis of exosomal contents isolated from samples using ultrafiltration and ultracentrifugation approaches and verified their nature using transmission electron microscopy, nanoparticle tracking analysis and flow cytometry. We observed that malignant neoplasm-associated proteins in exosomes from BCP total blood were detected more often than in plasma (66% vs. 59%). FunRich analysis to assess Gene Ontology (GO) enrichment revealed that proteins with catalytic activities, transporter functions and protein metabolism activities were increased in exosomes from BCP blood. Finally, GO analysis revealed that proteomic profiles of exosomes from HF total blood were enriched with proteins inhibiting cell migration and invasion, which explains the low stimulating activity of exosomes from HF total blood on SKBR-3 cancer cell migration velocity. This allows exosomes to act as intermediaries providing intercellular communications through horizontal transfer of RNA and functionally active proteins, potentially affecting the development of both primary neoplasms and distant metastases.

miRNAs are regulators of gene expression in diverse biological and pathological courses in life. Their discovery may be considered one of the most important steps in the story of modern biology. miRNAs are packed within exosomes and released by cells for cellular communications; they are present in bodily fluids. Their study opens the way for understanding the pathogenetic mechanisms of many diseases; furthermore, as potential candidate biomarkers, they can be measured in bodily fluids for non-invasive monitoring of disease outcomes. The present review highlights recent advances in the role of miRNAs in the pathogenesis of primary and secondary glomerulonephritides such as IgA nephropathy, focal segmental glomerular sclerosis, lupus nephritis and diabetic nephropathy. The identification of reciprocal expression of miRNAs and their target genes provides the molecular basis for additional information on the pathogenetic mechanisms of kidney diseases. Finally, recent findings demonstrate that miRNAs can be considered as potential targets for novel drugs.

Successful pregnancy requires an appropriate communication between the mother and the embryo(s). Recent studies indicate that exosomes, small (30–200 nm) membrane vesicles of endocytotic origin, could act as intercellular vehicles in this unique communication system. Exosomes have been identified in vivo in all body fluids including follicular, uterine, and oviductal fluids and can be secreted by most cell types in vitro. Bovine oviductal epithelial cells (BOEC) have been thoroughly used to study embryo-maternal communication and to improve embryo development in vitro. Hence, our objective was to provide a morphologic and proteomic characterisation of exosomes secreted by BOEC in vivo in the oviductal fluid and in vitro in the conditioned media. Oviducts from cows were flushed to recover in vivo exosomes and then BOEC were scraped in order to derive primary cultures. In vitro exosomes were collected from conditioned media of BOEC primary cultures after reaching confluence (10 days). Isolation of exosomes from in vivo and in vitro origin was performed by ultracentrifugation. The presence of exosomes was confirmed in oviductal flushings and conditioned media by electron microscopy. Further characterisation of exosomes was carried out based on morphology (transmission electron microscopy), size (dynamic light scattering, DLS), and protein composition (protein profile analysis by SDS-PAGE and Western immunoblotting). Preliminary results by DLS revealed different size distribution profiles in exosome samples (in vivo: mean size of 93.41 nm; in vitro: 433.5 nm). Because exosomes are considered as “micromaps” of the originating cells, protein patterns expressed by in vivo exosomes and in vitro exosomes were compared with scraped and cultured BOEC, respectively. Protein profile analysis by SDS-PAGE showed quantitative and qualitative differences among the exosome samples, their cells of origin, and the milieu (conditioned media or flushing). Exosome-specific protein bands were detected and will be further characterised. In addition, exosomes from in vivo and in vitro origin exhibited distinct proteomic profiles. Western blot analysis demonstrated that (1) both exosomal protein samples were positive for HSP70, a known exosomal protein, and negative for Grp78, an endoplasmic reticulum marker detected in BOEC; (2) in vivo exosomes expressed oviductal glycoprotein (OVGP), heat shock protein A8 (HSPA8), and myosin 9 (MYH9), 3 oviductal proteins with known roles in fertilization and early pregnancy. However, only HSPA8 and MYH9 were detected in in vitro exosomes. Our results provide the first extensive characterisation of oviductal exosomes from in vivo and in vitro origin, an essential step in furthering our understanding of the early embryo-maternal cross talk.

Summary Production from liquid-rich shale has become an important contributor to US production, but recovery factors are low. Enhanced-oil-recovery (EOR) methods require injectivity and interwell communication on reasonable time scales. Herein, we investigate the development of fracture interference for the application of recycled-lean-gas injection to displace reservoir fluids between zipper fractures in liquid-rich shales. In condensate systems, the liquids produced from miscible displacement could be extracted at the surface and the gas reinjected. In unconventional oil systems, immiscible displacement would occur with arrest in the oil-rate decline upon the onset of pressure support until immiscible front breakthrough, although this may never occur in a reasonable time. In either case, the time for interference is critical in assessment of process feasibility. Using superposition plus existing analytical solutions to the diffusivity equation for arbitrarily oriented line sources/sinks for pressure and new extensions for the pressure logarithmic temporal derivative, we analyze the time for interfracture-communication development (i.e., interference) and productivity index (PI) for both classical biwing fractures in a zipper configuration and complex-fracture networks. As a novel contribution, we demonstrate the ability to map both pressure and pressure temporal derivative as a function of time and space for production and/or injection from parallel motherbores under the infinite-conductivity wellbore and fracture assumption. The infinite-conductivity assumption could be relaxed later for more-general cases. We present the results in terms of geometrical-spacing requirement for both horizontal wells and stimulation treatments to achieve reasonable time frames for interfracture communication and sweep for parameters typical of various shale plays. Results can be used to determine whether spacing currently considered for primary production is sufficient for direct implementation of EOR or if current practice should be modified with EOR in the field-development plan.

The aim of moving particle semi-implicit (MPS) is to simulate the incompressible flow of fluids in free surface. MPS, when implemented, consumes a lot of time and thus, needs a very powerful computing system. Instead of using parallel computing system, the performance level of the MPS model can be improved by using graphics processing units (GPUs). The aim is to have a computing system that is capable of performing at high levels thereby enhancing the speed of processing the numerical computations required in MPS. The primary aim of the study is to build a GPU-accelerated MPS model using CUDA aimed at reducing the time taken to perform the search for neighboring particles. In order to increase the GPU processing speed, specific consideration is given towards the optimization of a neighboring particle search process. The numerical model of MPS is performed using the governing equations, notably the Navier-Stokes equation. The simulation model indicates that using GPU based MPS produce better performance compared to the traditional arrangement of using CPUs.

Abstract Extreme weather events including recently experienced prolonged heatwaves are predicted to increase in frequency and intensity as a result of climate change. Vulnerable groups, and particularly older persons, are at increased risk of heat-related illness and mortality. Multimodal interventions that incorporate community, primary and secondary care programmes are required. Social programmes such as early warning systems, regional heat plans and community-led initiatives that specifically target the isolated, dependent older person are protective. Establishing clear and effective communication on health promotion and preventative measures is the key. Energy-efficient building design and eco-city planning are vital to reduce the impact of heatwaves at both a population and individual level. Anticipatory strategies should be adopted to ensure ample access to fluids, target barriers to increase oral intake and allow early identification of intercurrent illness, along with regular medication reviews. Prompt management of risk factors for the development of heat-related illness and treatment of complications such as heat stroke and cardiovascular events are keys to reducing the negative health impact of extreme heat in at-risk populations. Morbidity and mortality in heatwaves should be preventable. Evidence-based interventions are available to mitigate and prevent the negative health impact of extreme heat and should be implemented in all residential settings.

TPS12129 Background: Positive treatment outcomes and avoidance of complications are dependent to a large extent on the care provided by family members. However, family caregivers report feeling unprepared to assume the multiple, complex tasks of caregiving, including tracheostomy care, tube feedings, wound and colostomy care, pain management, and emotional support. Despite being a critical extension of the oncology healthcare team, training of caregivers to manage symptoms, deal with communication issues with the care recipients, and take care of their own physical and emotional health as caregivers, is not integrated into clinical practice. The purpose of this clinical trial is to measure the effect of a psychoeducational caregiver intervention that incorporates simulation techniques focused on skill development to improve caregiver and patient outcomes. Simulation, commonly used in training healthcare professionals, is a form of experiential learning that creates events or situations to mimic clinical situations. Use of simulation for skills training in family caregivers of patients with cancer is rarely studied. Methods: This two-group, randomized clinical trial, which opened to accrual in December 2019, will recruit 180 caregivers from University Hospitals Seidman Cancer Center. Patients must be receiving radiation therapy for a diagnosis of stage I - III cancers of the rectum, anus, and esophagus; stage III NSCLC; or stage I – IV A/B head/neck cancer. Adult caregivers must be identified by the patient as their primary caregiver, who is providing daily assistance and/or emotional support. The intervention involves three in-person, one-on-one sessions during radiation treatments. The control group is usual care. Data will be collected at baseline, at the end of radiation treatment, and 4 and 20 weeks post-radiation treatment. The primary outcome is caregiver anxiety at 20 weeks postradiation treatment. Other caregiver outcomes include depression, health-related quality of life [HRQOL], and fatigue. Patient outcomes (HRQOL and interrupted treatment course) and healthcare utilization outcomes (unplanned hospital admission, emergency room visits, and use of intravenous fluids) will be measured. The analysis will consist of linear mixed model repeated measures, mediation and moderation tests, and Poisson regression methods. Clinical trial information: NCT04055948 .

The review material belongs to the scientific and practical issues related to the interdisciplinary direction on the border of nanotechnology, surface chemistry and physics, biology and medicine and is based on the use of natural components in the composition of iron-containing bioactive nanocomposites and magnetic fluids in creating effective vector systems for antitumor therapy with minimized side effects on the human body and improved compatibility with other drugs. Such natural components, which have unique properties, significant and not yet realized potential opportunities for practical use, include, in particular, lectins. The aim of the work is to select and analyze the results of works on the extraction of lectins, the study of their properties and application in biology and medicine. Lectins are a group of substances of protein nature (proteins and glycoproteins) of non-immune origin, which have the ability to reversely and selectively bind carbohydrates and carbohydrate determinants of biopolymers without changes in covalent structure and recognize them with extremely high specificity. Due to this property, they are an ideal tool for reading of code in the structure of specific sugar epitopes on the surface of all cells. Lectins are substances of primary synthesis and are present in all kingdoms, types and classes of living organisms. They mediate cellular communication at the molecular level and are involved in many physiological and pathophysiological processes. Pathogenic bacteria and viruses use lectins to attach to the host tissue, which is one of the prerequisites for the development of infection. Blocking of specific pathogen adhesion with lectin inhibitors is the basis of anti-adhesive therapy, an alternative method of treatment of infections caused by multidrug-resistant bacterial strains. Numerous lectins show antitumor activity and are being studied as potential antitumor drugs. To date, they have found practical application in a number of specialized medical fields, such as histology (detection of carbohydrate structures on the surface of cells and tissues), diagnosis of immunodeficiency and chromosomal abnormalities, transplantology (separation of blood cells and lymphoid cells with different antigenic properties). The prospect of use of lectins in the purification of blood from viruses, pathologically altered glycoproteins, in the targeted delivery of drugs to normal or pathologically altered cells and tissues of the body or to infectious agents is considered very significant. The combination of properties of lectins and magnetically sensitive iron-containing nanocomposites in the composition of magnetic fluids for use in oncology is considered relevant and promising.

Summary Ewing Bank 873 is an offshore Gulf of Mexico field discovered in 1991 in 775 ft of water. The discovery well was drilled on a seismic amplitude anomaly on the flank of a salt withdrawal minibasin. Field development began in 1994, and in mid-1998 daily production from the Bulminella 1 reservoir averaged 40,000 BOPD and 32×106 ft3/D of gas. The Bul 1 reservoir in this combination structural-stratigraphic trap consists of six stacked and overlapping Pliocene turbidite sand lobes. In turn, integration of seismic, well log, geochemical and pressure data indicates these six turbidite lobes comprise three compartments. All of the various data types give constraints on different aspects of compartmentalization, but at the stratigraphically complex Ewing Bank 873 field, geochemical analyses provided key information unavailable through any other means. These geochemical analyses were performed as individual wells in the field went on production and immediately provided information regarding fluid communication and reservoir connectivity that was missing from earlier interpretations based solely on seismic and log data. Early recognition of three reservoir compartments using geochemical data also helped constrain preliminary stratigraphic interpretations and provided initial input for flow units and reservoir simulation models. The geochemical information further provided advance notice of economically significant oil quality variations in the three compartments. These fluid variabilities were later substantiated by pressure/volume/temperature analyses and include notable differences in oil gravity, weight percent sulfur, viscosity and solution gas. Integrating all available data shows there are three compartments at Ewing Bank 873 and each compartment comprises different turbidite sand lobes and exhibits its own characteristic pressure regime and fluid properties. The early indications of both compartmentalization and variation in fluid properties by the geochemical analyses contributed significantly to improved field recovery and economics by allowing fewer and better placed wells to be drilled. Introduction Development of deepwater Gulf of Mexico fields is an expensive undertaking that involves considerable analysis and evaluation of both engineering and geologic data. In this context, failure to recognize reservoir compartmentalization can add significantly to field development capital and result in less than optimum reservoir management. For all of these reasons, early recognition of reservoir compartmentalization is advantageous. Traditionally, pressure, seismic and log data have been among the primary tools used to identify compartmentalization. Each of these techniques provides information on a different aspect of reservoir compartmentalization, and the various methodologies work best when integrated. For example, at Ewing Bank 873 the pre-drill seismic data provide the gross geometry and lateral distribution of the different turbidite sand packages,1 but the seismic cannot resolve individual sand lobes. Well logs do show individual sand lobes, but in this instance, where turbidite lobes are characterized by compensation-style bedding, correlation of sands is difficult. Pressure data also yield valuable information on reservoir compartmentalization, but long term build-up tests can be expensive to obtain and involve shutting in production. In addition to these techniques, another tool for identifying reservoir compartmentalization that complements the other analyses by providing a direct indication of reservoir fluid continuity is geochemistry. Over the past 10 years, a number of case studies2–10 have clearly demonstrated the value of geochemistry in recognizing reservoir compartmentalization. In particular, geochemical analysis of oils by gas chromatography is an inexpensive technique requiring minimal turnaround time that provides information on compartmentalization early in the history of a reservoir. In turn, early recognition of compartmentalization can help in the placement of development wells and optimize new field development choices. Beyond early recognition of compartmentalization, geochemical analysis at Ewing Bank 873 also helped constrain reservoir simulations, assisted in correlation of reservoir sand units and aided in understanding oil quality variations within the reservoir. This case history further demonstrates how geochemical analyses provide a unique opportunity to characterize a reservoir from the perspective of the actual reservoir fluids rather than from the perspective of the "container" holding those fluids. However, it is only by integrating all of the reservoir data—geochemical, seismic, log, pressure and stratigraphic—that reservoir management can be optimized. Geologic Setting and Field Description Ewing Bank 873 is a deepwater (775 ft) Gulf of Mexico field that is almost 200 miles due south of New Orleans (Fig. 1) and lies along the flexure trend between the current shelf and continental slope. This field was discovered in 1991 by drilling a seismic amplitude anomaly on the flank of a salt withdrawal minibasin (Fig. 2). The reservoir is a series of six stacked and overlapping Pliocene Bulminella 1 (3.8 Ma) deepwater turbidites. The trap at Ewing Bank 873 is a combination stratigraphic/structural trap formed by updip pinch out of the turbidite sands and by faults on the eastern and western margins of the field. Updip sand pinch out is in turn controlled by an underlying salt diapir.

INTRODUCTION. Recent studies show that ~25% of newly diagnosed multiple myeloma patients treated with 8 cycles of bortezomib, lenalidomide and dexamethasone (VRd) achieve minimal residual disease (MRD) negativity. Recently, 42% stringent complete response (sCR) rates were reported with the use of VRd combined with the CD38-targeted monoclonal antibody daratumumab (VRd-D). Here, we present the final results from a phase 2 study using weekly dosing of carfilzomib 56 mg/m2 with lenalidomide and dexamethasone in combination with daratumumab (wKRd-D). The primary endpoint of our study was to demonstrate >60% and to target up to 80% MRD negativity rate with wKRd-D. METHODS. This phase II clinical trial is based on Simon's optimal two-stage design. The wKRd-D dosing schedule is as follows: 8 cycles of treatment; 28-day cycles with IV carfilzomib 20/56 mg/m2 days 1, 8, and 15; PO lenalidomide 25 mg days 1-21; PO/IV dexamethasone 40 mg weekly cycles 1-4, 20 mg after cycle 4; and IV daratumumab 16 mg/kg days 1, 8, 15, and 22 cycles 1-2, days 1 and 15 cycles 3-6, and day 1 cycles 7-8. For fit patients, stem cell collection is recommended after 4 to 6 cycles of therapy; wKRd-D therapy resumed after collection to a total of 8 cycles wKRd-D. Treatment response is being assessed with parallel bone marrow-based MRD assays (10-color single tube flowcytometry and invivoscribe IGHV sequencing); per IMWG guidelines both MRD assays allows detection of 1 myeloma cell in 100,000 cells (10^-5). Baseline bone marrow samples are evaluated with targeted DNA sequencing for FISH-Seq and somatic mutational characteristics (myTYPE). RESULTS. The study is fully enrolled; between October 2018 and November 2019 a total of 41 evaluable patients were enrolled. Baseline characteristics include; median age 59 years (range 30-70 years); 25 (61%) females;16 (39%) males; 20 (49%) patients had high-risk FISH/SNP signature defined as one or more of the following: 1q+, t(4;14), t(14;16), t(14;20), and 17p-. At submission of this abstract, 39 out of 41 patients have completed 8 cycles of treatment and end of treatment evaluations. Of those 39, 29 patients were MRD negative and 10 patients MRD positive. Two patients are pending end of treatment evaluations for response (currently receiving cycle 8 of wKRd-D). Thus, among patients treated on the weekly cohort (wKRd-D) and who were evaluable for the MRD primary endpoint at this analysis, we found 29/39 (74%) to be MRD negative. We further show no added major clinical toxicities with wKRd-D compared to our institution standard of care KRd. At a median follow-up of 10 months, none of the MRD negative patients have progressed. Among 29 patients found to be MRD negative after 8 cycles of wKRd-D, 2 patients have been assessed for MRD at 1 year of follow-up and 2/2 (100%) show 1-year sustained MRD negativity. There are no deaths on the study. CONCLUSIONS. Among patients evaluable for the MRD primary endpoint, in the absence of an autologous bone marrow transplant, here we show a 29/39 (74%) MRD negativity rate among newly diagnosed multiple myeloma patients treated with wKRd-D, including weekly carfilzomib 56 mg/m2 dosing. At a median follow-up of 10 months, none of the MRD negative patients have progressed. These results compare favorably with previously published results with KRd, VRd, or VRd-D. Using optimized IV fluid management (250 ml saline prior to first dose of carfilzomib only, and thereafter no IV fluids) coupled with baseline work-up with EKG/echocardiograms for all patients, we did not observe excess rates of cardiovascular or renal adverse event. The wKRd-D dosing schedule has a total of 27 infusions and offers an attractive treatment modality for newly diagnosed multiple myeloma patients. Based on these promising results, a large randomized multi-center study ("ADVANCE") evaluating wKRd-D in relation to established standard of care has been opened for enrollment. Disclosures Landgren: Adaptive: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Juno: Consultancy, Honoraria; Cellectis: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Binding Site: Consultancy, Honoraria; Karyopharma: Research Funding; Merck: Other; Pfizer: Consultancy, Honoraria; Seattle Genetics: Research Funding; Juno: Consultancy, Honoraria; Glenmark: Consultancy, Honoraria, Research Funding; Cellectis: Consultancy, Honoraria; Glenmark: Consultancy, Honoraria, Research Funding; Takeda: Other: Independent Data Monitoring Committees for clinical trials, Research Funding; Amgen: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Other: Independent Data Monitoring Committees for clinical trials, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Seattle Genetics: Research Funding; Merck: Other; Pfizer: Consultancy, Honoraria; Takeda: Other: Independent Data Monitoring Committees for clinical trials, Research Funding; Binding Site: Consultancy, Honoraria; Karyopharma: Research Funding; Janssen: Consultancy, Honoraria, Other: Independent Data Monitoring Committees for clinical trials, Research Funding. Hultcrantz:Intellisphere LLC: Consultancy; Amgen: Research Funding; GSK: Research Funding; Daiichi Sankyo: Research Funding. Lesokhin:BMS: Consultancy, Honoraria, Research Funding; Genentech: Research Funding; Janssen: Research Funding; GenMab: Consultancy, Honoraria; Juno: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Serametrix Inc.: Patents & Royalties. Mailankody:Janssen Oncology: Research Funding; Juno Therapeutics, a Bristol-Myers Squibb Company: Research Funding; Allogene Therapeutics: Research Funding; PleXus Communications: Honoraria; Physician Education Resource: Honoraria; Takeda Oncology: Research Funding. Hassoun:Novartis: Consultancy; Celgene: Research Funding; Takeda: Research Funding. Shah:Celgene/BMS: Research Funding; Physicians Education Resource: Honoraria. Scordo:McKinsey & Company: Consultancy; Angiocrine Bioscience, Inc.: Consultancy, Research Funding; Omeros Corporation: Consultancy; Kite - A Gilead Company: Other: Ad-hoc advisory board. Chung:Genentech: Research Funding. Shah:Amgen Inc.: Research Funding; Janssen: Research Funding. Lahoud:MorphoSys: Other: Advisory Board. Thoren:The Binding Site: Research Funding; Sebia: Research Funding. Murata:Abbott Laboratories: Research Funding. Ho:Invivoscribe, Inc.: Honoraria. Dogan:Roche: Consultancy, Research Funding; Physicians Education Resource: Consultancy; Corvus Pharmaceuticals: Consultancy; Seattle Genetics: Consultancy; Takeda: Consultancy; EUSA Pharma: Consultancy; AbbVie: Consultancy; National Cancer Institute: Research Funding. Giralt:CSL Behring: Research Funding; Jazz: Research Funding; Actinuum: Research Funding; Amgen: Research Funding; Janssen: Research Funding; Celgene: Research Funding; Quintiles: Research Funding; Pfizer: Research Funding; Sanofi: Research Funding; Adienne: Research Funding; Kite: Research Funding. Korde:Astra Zeneca: Membership on an entity's Board of Directors or advisory committees; Amgen: Research Funding. OffLabel Disclosure: Daratumumab, Carfilzomib, Lenalidomide, and Dexamethasone in Newly-Diagnosed Multiple Myeloma. These drugs are included in the current clinical and correlative Phase II study

Summary Water-injection-induced fractures are key factors influencing successful waterflooding projects. Controlling dynamic fracture growth can lead to largely improved water-management strategies and, potentially, to increased oil recovery and reduced operational costs (well-count and water-treatment-facilities reduction), thereby enhancing the project economics. The primary tool that reservoir engineers require to guarantee an optimal waterflood field implementation is an appropriate modeling tool, which is capable of handling the dynamic fracturing process in complex reservoir grids. We have developed a new modeling strategy that combines fluid flow and fracture growth in one reservoir simulation. Dynamic fractures are free to propagate in length and height-direction with respect to poro- and thermoelastic stresses acting on the fracture. A prototype simulator for contained fractures was tested successfully. We have extended the coupled simulator to incorporate noncontained fractures. The new simulator, called FRAC-IT, handles fracture-length and -height growth by evaluating a fracture-propagation criterion on the basis of a Barenblatt (1962) condition. The solution of the 5D problem is computed by use of a tuned Broyden (1965) approach. We demonstrate the capabilities of the coupled simulator by showing its application to a complex reservoir-simulation model. The fracture modeling is used to history match an injectivity test in a five-spot injection pattern using produced water. The coupled-simulation results and the field-data interpretation show a very good match. The outcome of the injection test led to an appropriate waterflood-management strategy adapted to the specific reservoir conditions and, in terms of production, to a net oil-production increase of 50 to 100%. The field example shows how the coupled-simulator technology can be used to achieve optimized waterflood-management strategies and increased oil recovery. Introduction Waterflooding is often applied to increase the recovery of oil in mature reservoirs or to maintain the reservoir pressure above bubblepoint in the case of green fields. Even though often unnoticed, water injection frequently is taking place under induced-fracturing conditions. The rock fracturing has a strong influence on the water injectivity and the areal distribution of the fluids in the reservoir. A qualitative example of the impact of the fracture orientation on the areal sweep is demonstrated in Fig. 1. We show streamlines in two different water-injection-pattern configurations for two fracture orientations (i.e., line-drive and five-spot geometry, and fracture oriented toward the producer and away from the producer. The density of the streamlines indicates that the fracture orientation changes the areal sweep. In order to achieve optimized water-injection management, dynamic fracture propagation needs to be estimated properly before the injection, controlled during operations, and monitored to ensure predictions and reality do not deviate significantly. The tools commonly used to study fracture growth numerically are analytical fracture simulators, which often are based on a single-well model in a simplified reservoir formation. Generally, reservoir heterogeneity is reduced to a number of horizontal layers with homogeneous properties and a laterally infinite extent. Fracture propagation is described using a pseudo-3D description (van den Hoek et al. 1999). For many field developments under waterflooding, fracture propagation is estimated with acceptable error bars using these or similar tools. The major drawbacks areAreal reservoir heterogeneity is not accounted for.Varying poro- and thermoelastic stresses along the fracture are neglected.Injection pressures have large error bars because the reservoir response is not properly captured.Nearby well's influences (e.g., pattern flood) are not captured. In the past, many attempts have been made to address these issues. Common approaches can be grouped into fully implicit simulators (Tran et al. 2002), where both fluid-flow and geomechanical equations are solved simultaneously on the same numerical grid, and coupled simulators (Clifford et al. 1991), where a standard, finite-volume reservoir simulator is coupled to a boundary-element-based fracture-propagation simulator. To our knowledge, both approaches are not standard and currently not used in the industry becauseModels need to be purpose built (i.e., reservoir models from standard reservoir simulator cannot be used).Fracture propagation is oversimplified.Numerical stability is questionable. We have developed an extension to an existing reservoir simulator to circumvent these shortcomings. We use a coupled-simulator approach based on a two-way communication strategy between the fully numerical reservoir simulator and the half-analytical geomechnical-modeling part. The new simulator enables the modeling of fluid flow and dynamic fracture propagation in a combined way. We have applied the tool to field applications for waterflooding projects in which injector/producer shortcuts are a potential risk (pattern floods) and also to environments in which fracture containment and estimating accurate injection pressures are the main concerns. In this paper, we briefly review the coupled-simulator approach and discuss the application to a waterflooding field example.

Abstract Introduction The Malnutrition Universal Screening Tool (MUST) is a nationally validated risk tool, used to identify adults who are malnourished. 40% of surgical patients are malnourished which significantly impacts the outcomes of elderly patients. The primary aim of this study was to ascertain its utilisation in elderly patients undergoing trauma and orthopaedic surgery in a district general hospital. Method We completed a closed-loop audit from October2019-June2020 over two, three-week periods Inclusion criteria was age ≥65 years, and patients undergoing surgery. Data collected included MUST score, nutritional support, pre-operative fasting time, and prescription of fluids. Our intervention included departmental teaching sessions, posters, and the addition of the MUST tool to clerking proformas. Results We included analysis of 70 patients. Following our intervention, admission MUST score calculation improved by 8%, and providing nutritional support increased by 21%. However, there was no improvement in reducing pre-operative fasting time and prescription of pre-operative fluids. Conclusions Through our intervention’s documentation and assessment of nutritional status in elderly patients has improved. However further work must be completed to reduce time spent ‘nil-by-mouth’ and prescribe fluids for maintenance before surgery. This requires better pre-operative planning and communication between the surgical and ward-based teams.

ABSTRACT Gram-positive bacteria utilize exported peptides to coordinate genetic and physiological processes required for biofilm formation, stress responses, and ecological competitiveness. One example is activation of natural genetic competence by ComR and the com X -inducing peptide (XIP) in Streptococcus mutans. Although the competence pathway can be activated by the addition of synthetic XIP in defined medium, the hypothesis that XIP is able to function as an intercellular signaling molecule has not been rigorously tested. Coculture model systems were developed that included a “sender” strain that overexpressed the XIP precursor (ComS) and a “responder” strain harboring a green fluorescent protein (GFP) reporter fused to a ComR-activated gene (comX) promoter. The ability of the sender strain to provide a signal to activate GFP expression was monitored at the individual cell and population levels using (i) planktonic culture systems, (ii) cells suspended in an agarose matrix, or (iii) cells growing in biofilms. XIP was shown to be freely diffusible, and XIP signaling between the S. mutans sender and responder strains did not require cell-to-cell contact. The presence of a sucrose-derived exopolysaccharide matrix diminished the efficiency of XIP signaling in biofilms, possibly by affecting the spatial distribution of XIP senders and potential responders. Intercellular signaling was greatly impaired in a strain lacking the primary autolysin, AtlA, and was substantially greater when the sender strain underwent lysis. Collectively, these data provide evidence that S. mutans XIP can indeed function as a peptide signal between cells and highlight the importance of studying signaling with an endogenously produced peptide(s) in populations in various environments and physiologic states. IMPORTANCE The comX-inducing peptide (XIP) of Streptococcus mutans is a key regulatory element in the activation of genetic competence, which allows cells to take up extracellular DNA. XIP has been found in cell culture fluids, and the addition of synthetic XIP to physiologically receptive cells can robustly induce competence gene expression. However, there is a lack of consensus as to whether XIP can function as an intercellular communication signal. Here, we show that XIP indeed signals between cells in S. mutans, but that cell lysis may be a critical factor, as opposed to a dedicated secretion/processing system, in allowing for release of XIP into the environment. The results have important implications in the context of the ecology, virulence, and evolution of a ubiquitous human pathogen and related organisms.

The theme for this issue of M/C is 'renew'. This is a term that could be approached in numerous ways: as a cultural practice, in terms of broader dynamics of change, in terms of the future of the journal. In this piece, however, I'd like to narrow the focus and think about renewal in the context of the concept of 'media' and media theory. This is not to diminish the importance of looking at media in relation to changing technologies, and changing cultural contexts. Indeed, most readers of M/C will no doubt be aware of the dangers of positing media outside of culture in some kind of deterministic relationship. Indeed, the slash in the title of M/C -- which since its first editorial both links and separates the terms 'media' and 'culture' -- is interesting to think about here precisely because the substitution of the 'and' opens up a questioning of the relation between the two terms. While I too want to keep the space between media / culture filled with possibility, in this piece I want to look mainly at one side of the slash and speculate on renewal in the way we relate to ideas of media. Since its first editorial the slash has also been a marker of M/C's project to bridge academic and popular approaches, and work as a cross-over journal. In the hope of not stretching the cross-over too far, I'd like to bring contemporary philosophy into the picture and keep it in the background while thinking about renewal and the concept of 'media'. A key theme in contemporary philosophy has been the attempt to think difference beyond any opposition of the One and the Many (Patton 29-48; Deleuze 38-47). In an effort to think difference in its own terms, philosophers like Gilles Deleuze and Jacques Derrida have resisted seeing difference as something dependant on, derivative or secondary to a primary point of sameness and identity. In this brief piece, and out of respect of M/C's project, my intention is not to summarise this work in detail. Rather, I want to highlight the existence of this work in order to draw a contrast with the way in which contemporary thinking about media often seems caught up in a dynamic of the One and Many, and to pose the question of a different path for media theory. Having mentioned philosophy, I do want to make the point that 'One or Many Media' is not just an abstract formulation. On the contrary, the present day is a particularly appropriate time to look at this problem. Popular discussion of media issues itself oscillates between an idea of Media dominance (the One) and an idea of multiple media (multimedia). Discussions of convergence frequently invoke a thematics of the One arising out of the Many, or of the Many arising from the One. Medium, Media, the Media. Which one to use? We need only to list these three terms to begin see how the tension between the One and the Multiple has influenced contemporary thinking about media. An obvious tension exists on the level of grammar. 'Media' is the plural of 'Medium'. That is, until we use the term 'the Media' which can be used to refer to the singularity of (a specific area of) the Press. Walter Ong dubs 'medium' "the fugitive singular" to describe this phenomenon (175). To compensate for the increasing use of 'the media' as a singular it is becoming more common to see the term 'mediums' instead of 'media'. A second tension exists on the level of the senses. 'The media', and in some senses a 'medium', conveys the notion of a media form distinct from the senses. As Michael Heim notes, Medium meant conceptual awareness in conjunction with the five senses through which we come to understand things present before us in the environment. This natural sense of media was gradually dissipated during the modern period by man-made extensions and enhancements of the human senses ... . Electronic media gave new meaning to the term. We not only perceive directly with five senses aided by concepts and enhanced by instrumentation, but also are surrounded by a panorama of man-made images and symbols far more complex than can be assimilated directly through the senses and thought processes. Media in the electronic sense of acoustic-optic technology ... appear to do more than augment innate human sensory capacities: the electronic media become themselves complex problems; they become facts of life we must take into account as we live; they become, in short, the media. (47) In this passage, Heim shows how through extension and instrumentation 'the media' comes to occupy a different register of existence. 'The media' in this account are distinct from any general artefact that can serve as a means of communication to us. On this register, 'the media' also develops into the idea of the mass media (see Williams 169). In popular usage this incorporates print and broadcasting areas (usually with a strong journalistic emphasis), and is often personified around a notion of 'the media' as an agent in the contemporary political arena (the fourth estate, the instrument of a media baron). This brings us to a third tension, to do with diversity. The difference between the terms 'Medium', 'Media', 'the Media', is clearly bound up with the issue of diversity and concentration of media. Sean Cubitt argues that a different activation of interactive media, intermedia, or video media, is crucial to restoring an electronic ecology that has been destroyed by the marketplace (207). What the work of theorists like Cubitt reveals is that the problem of diversity and concentration has a conceptual dimension. Framed within an opposition between the One and the Multiple, the diversity in question -- of different senses and orders of media -- is constrained by the dominant idea of the Media. Many theorists and commentators on 'the Mass media' barely acknowledge the existence of video media unless it is seen as a marketplace for the distribution of movies. This process of marginalisation has been so thorough that the contemporary discussion of the Internet or interactive digital media often ignores previous critical discussion of the electronic arts -- as if McLuhan had no connection with Fluxus, or convergence had no links to intermedia experimentation. In a different example, it is becoming common to discuss 'personal media' like laptops and intelligent jewellery (see Beniger; Kay and Goldberg). But if media theory has previously failed to look at T-shirts and other personal effects as media then this is in part due to the dominance of the idea of the mass media in conceptual terms. This dominance leads Umberto Eco to propose an idea of the "multiplication of the media" against the idea of mass media, and prompts him to declare that "all the professors of theory of communications, trained by the texts of twenty years ago (this includes me) should be pensioned off" (149). It could be argued that rather than represent a problem the sliding between these terms is enabling not disabling. From this perspective, the fact that different senses of media collapse or coalesce with one another is appropriate, since (as I hope I've shown) different senses of media are often grounded in other senses. Indeed, we can agree with this argument, and go further to suggest that renewing our relationship to concepts of media involves affirming the interplay of different senses of media. What needs careful consideration here, however, is how we think of different senses of media. For it is very often the case that this question of difference is blocked from discussion when an order of media is used to secure a territory or a foundation for a particular idea of how things should work. From this foundation particular ideas of One-ness/Same-ness or Many-ness can emerge, each of which involves making assumptions about differences between media, and the nature of difference. Examples might include notions of mainstream and alternative, professional and non-professional, 'industry' and 'artistic' ways of working.1 In each case a dominant idea of the media establishes itself as an order against which other practices are defined as secondary, and other senses of media subordinate. Surveying these tensions (grammatical, sensory and diversity) between the terms 'Medium', 'Media', 'the Media', what becomes apparent is that neither of them is able to stand as 'the' primary conceptual term. Attempting to read contemporary developments in light of the One of the mass media means that theory is often left to discuss the fate of an idea, broadcasting, that represents only one way of organising and articulating a medium. Certainly, this approach can yield important results on the level of audience studies and identity politics, and in respect to government policy. Jock Given's work on broadcasting as a "set of technologies, social and cultural practices, cultural forms, industries, institutional forms, words and an idea" usefully contests the idea that broadcasting is dying or has no place in the digital future (46). However, research of this kind is often constrained by its lack of engagement with different orders of media, and its dependence on an idea of the One medium that is now under erasure.2 Attempting to read contemporary developments in light of the One of the mass media means that theory is often left to discuss the fate of an idea, broadcasting, that represents only one way of organising and articulating a medium. Certainly, this approach can yield important results on the level of audience studies and identity politics, and in respect to government policy. Jock Given's work on broadcasting as a "set of technologies, social and cultural practices, cultural forms, industries, institutional forms, words and an idea" usefully contests the idea that broadcasting is dying or has no place in the digital future (46). However, research of this kind is often constrained by its lack of engagement with different orders of media, and its dependence on an idea of the One medium that is now under erasure.2 Exploring the potential of 'Medium' as a primary term leads again into the problem of the One and the Many. The content of every medium may be, as McLuhan said, another medium (8). But we should search for the hidden One that binds together the Many. Indeed, multimedia can precisely be seen in this way: as a term that facilitates the singularising of multiple media. In a historically significant 1977 paper "Personal Dynamic Media" by Alan Kay and Adele Goldberg, we read that the essence of a medium is very much dependent on the way messages are embedded, changed, and viewed. Although digital computers were originally designed to do arithmetic computation, the ability to simulate the details of any descriptive model means that the computer, viewed as a medium itself, can be all other media if the embedding and viewing methods are sufficiently well provided. (255) It is following this passage that Kay and Goldberg use the term "metamedium" to describe this system, which effectively seals the Many into the One, and compromises any sense that 'multimedia' can fully live up to the idea of multiple media. Situating the term 'media' as a primary term is interesting primarily because Heim deems it the "natural sense of media". There is some value in re-asserting the most general understanding of this idea, which is that any artefact can serve to communicate something to the senses. That said, any exploration of this kind needs to keep a critical eye not just on the McLuhanesque extension of the senses that Heim mentions, but also the imperative that these artefacts must mediate, and function as a means of communication. In other words, any celebration of this conception of media needs to be careful not to naturalise the idea that communication is the transmission of ideal contents. As Derrida's work shows, a complex system is required for a media to work in this way. It is only via a particular system of representation that a medium comes to serve as a vehicle for communication (311-2). As such, we should be wary of designating this idea of media as 'natural'. There are of course other reasons to be cautious with the use of the term 'natural' in this context. Contemporary usage of 'media' show that the human sensorium has already entered a complex cyborg future in which human actions, digital files, data, scripts, can be considered 'media' in a performance work or some other assemblage. Contemporary media theory resolves some of the problems of the terms 'Medium', 'Media', 'the Media' serving as a primary conceptual figure by reading them against one another. Thus, the mass media can be criticised from the point of view of the broader potential of the medium, or transformations in a medium can be tracked through developments in interactive media. Various critical or comparative approaches can be adopted within the nexus defined by these three terms. One important path of investigation for media theory is the investigation of hybrid mixed forms of media as they re-emerge out of more or less well defined definitions of a medium. A concern that can be raised with this approach, however, is that it risks avoiding the problem of the One or Many altogether in the way it posits some media as 'pure' or less hybrid in the first instance. In the difficult process of approaching the problem of One or Many media, media theory may find it worthwhile listen in on discussion of the One or Many opposition in contemporary philosophy. Two terms that find a prominent place in Deleuze's discussion of the multiplicity are "differentiation" and "actualisation". I'd want to suggest that both terms should hold interest for media theorists. For example, in terms of the problem of One or Many Media, we can note that differentiation and actualisation have not always been looked at. Too often, the starting point for theories of media is to begin with a particular order of media, a conception of the One, and then situate multiple practices in relationship to this One. Thus, 'the media' or 'mass media' is able to take the position of centre, with the rest left subordinate. This gesture allows the plural form of 'media' to be dealt with in a reductive way, at the expense of an analysis of supposed plurality. (It also works to detach the discussion of the order of media in question from other academic and non-academic disciplines that may have a great deal to say about the way media work.) A different approach could be to look at the way this dominant order is actualised in the first place. Recognition that a multiplicity of different senses of media pre-exists any single order of media would seem to be a key step towards renewal in media theory. This piece has sought to disturb the way a notion of the One or Many media often works in the space of media theory. Rather than locate this issue in relation to only one definition of media or medium, this approach attempts to differentiate between different senses of media, ranging from those understandings linked to the human sensorium, those related to craft understandings, and those related to the computerised manipulation of media resources. The virtue of this approach is that it tackles head on the issue that there is no one understanding of media that can function as an over-arching term in the present. The human senses, craft, broadcasting, and digital manipulation are all limited in this respect. Any response to this situation needs to engage with this complexity by recognising that some understandings of media exceed the space of a medium. These other understandings can form useful provisional points of counter-actualisation.4 Footnotes Recent Australian government decisions about the differences between digital television and datacasting would be interesting to examine here. In relation to Given's work I'd suggest that a fuller examination of media's digital future needs to elaborate on the relationship between 'the media' and alternative understandings of the term in computing, for example, such as Kay and Goldberg's. In this way, the issue of future conceptions of media can be opened up alongside the issue of a future for the media. Monaco's, "Mediography: In the Middle of Things" is a rare example. In the section 'Levels of the Game' Monaco usefully distinguishes between different orders of media. My thanks to the anonymous M/C reviewers for their useful comments, and also Anna Munster for her suggestions. References Beniger, James R. "Personalisation of Mass Media and the Growth of Pseudo-Community." Communication Research 14.3 (June 1987): 352-71. Cubitt, Sean. Videography: Video Media as Art and Culture. London: Macmillan, 1993. Deleuze, Gilles. Bergsonism. Trans. Hugh Tomlinson and Barbara Habberjam. New York: Zone, 1991. Derrida, Jacques. Margins of Philosophy. Trans. Alan Bass. Brighton, Sussex: Harvester, 1986. Eco, Umberto. "The Multiplication of the Media." Travels in Hyper-Reality. Trans. William Weaver. London: Pan, 1986. 145-50. Given, Jock. The Death of Broadcasting: Media's Digital Future. Kensington: U of New South Wales P, 1998. Heim, Michael. Electric Language: A Philosophical Study of Word Processing. New Haven and London: Yale UP, 1987. Kay, Alan, and Adele Goldberg. "Personal Dynamic Media." A History of Personal Workstations. Ed. Adele Goldberg. New York: ACM/Addison-Wesley, 1988. 254-63. McLuhan, Marshall. Understanding Media: The Extensions of Man. London: Routledge and Kegan Paul, 1964. Monaco, James. "Mediography: In the Middle of Things." Media Culture. Ed. James Monaco. New York: Delta, 1978. 3-21. Ong, Walter. Orality and Literacy: The Technologising of the Word. London: Methuen, 1982. Patton, Paul. Deleuze and the Political. London: Routledge, 2000. Williams, Raymond. Keywords: A Vocabulary of Culture and Society. London: Fontana, 1976. Citation reference for this article MLA style: Steven Maras. "One or Many Media?" M/C: A Journal of Media and Culture 3.6 (2000). [your date of access] <http://www.api-network.com/mc/0012/many.php>. Chicago style: Steven Maras, "One or Many Media?" M/C: A Journal of Media and Culture 3, no. 6 (2000), <http://www.api-network.com/mc/0012/many.php> ([your date of access]). APA style: Steven Maras. (2000) One or many media? M/C: A Journal of Media and Culture 3(6). <http://www.api-network.com/mc/0012/many.php> ([your date of access]).

The prevalence of advanced dementia (AD) is expected to increase dramatically over the next few decades. Patients with AD suffer from recurrent episodic illnesses that frequently result in transfers to acute care hospitals. The default pathway followed by some emergency physicians, internists and intensivists who see those patients is to prioritize disease-directed therapies over attention to the larger picture of AD. While this strategy is desired by many families, some families prefer a different approach. This essay examines the reason why there can be a failure to focus on the over-arching issue of AD and offers suggestions for improvement. Gaps in information and physician workload are important factors, but we argue that until physicians who see patients in emergency departments learn to pause first and ask “Why are we doing this?” they will revert to their comfort zone of ordering tests and therapies that may be unwanted. A separate emergency palliative care pathway may be one solution. Shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment may alter the trajectory of care in ways that truly respect the wishes of some patients and their families. On s’attend à ce que la prévalence de la démence avancée (DA) augmente de façon extrêmement importante au cours des prochaines décennies. Or, il arrive que des patients atteints de DA soient aux prises avec des maladies épisodiques récurrentes qui entraînent fréquemment un transfert dans un hôpital de soins actifs. La voie suivie par défaut par certains urgentologues, internistes et intensivistes qui reçoivent ces patients consiste à donner la priorité à l’application de traitements axés sur la maladie plutôt qu’à aborder le problème plus large de la DA. Cette stratégie satisfait bien des familles, mais certaines préfèrent une autre approche. Cet article examine pourquoi on semble vouloir éviter de s’attarder au problème récurrent de la DA et offre des suggestions d’amélioration. Des lacunes en matière d’information ainsi que la charge de travail des médecins sont sûrement des facteurs importants qui mènent à cette situation. Toutefois, nous soutenons que tant que les médecins qui voient ces patients au service des urgences ne prendront pas le temps de s’arrêter et de se questionner sur leur choix d’actions, ils se limiteront à se retirer dans leur zone de confort qui consiste à prescrire des tests et des traitements qui risquent d’être inopportuns. Une voie distincte en matière de soins palliatifs d’urgence peut s’avérer être une solution. En déplaçant l’accent mis sur les troubles physiologiques du moment pour le mettre sur le problème plus large de la DA, la trajectoire des soins pourrait être modifiée de façon à mieux respecter les désirs de certains patients et de leur famille.An 84-year-old bed-bound man with severe Alzheimer’s dementia presents to the emergency department with pneumonia, accompanied by his 3 daughters. He has been hospitalized 4 times in the past 2 years for antibiotic-associated Clostridium difficile diarrhea. Antibiotics and intravenous fluids were started by the first physicians who saw him. An internist was consulted to take over his care.In 2016, 564,000 Canadians were living with dementia. Each year 25,000 new cases of dementia are diagnosed, and it is expected that by 2030 there will be close to 1 million Canadians who have dementia.1 People with advanced dementia (AD) suffer with cognitive deficits and are unable to communicate, ambulate and have incontinence. They are at high risk for imminent death,2,3 an under-recognized fact even among health care professionals.4 In contrast to patients with terminal cancer and end stage heart disease, most patients with AD do not die from devastating acute events (like bowel obstruction, or heart failure) that result from the progression of their primary disease. Instead, they die from recurrent episodic illnesses that can be treated with relatively simple therapeutic responses (like intravenous fluids or antibiotics). 3 These include pneumonias, urinary tract and skin infections, influenza, problems with eating (including aspiration) and dehydration. It is not surprising that in the United States that 19% of nursing home residents with cognitive impairment experience at least one transfer to a hospital in the last 120 days of life.5When these patients arrive in the emergency department (ED), the default pathway is to prioritize disease-directed therapies (e.g., intravenous fluid and antibiotics) over attention to the larger picture of AD. The physiologic disturbances receive intense focus and the AD is seemingly forgotten. These patients often suffer from treatable symptoms, including pain and shortness of breath.3 In some (but not all) cases, patients may receive care they don’t really want, families may be afraid to express their true wishes, and health care professionals may deliver care they suspect is unnecessary, or even harmful. This essay examines the reasons why this phenomenon occurs and offers suggestions for improvement by encouraging acute care clinicians to pause and ask themselves, “Why are we doing this?” and by engage family members in focused goals of care discussions that include outcomes of aggressive disease-directed treatments and palliative approaches.There are many reasons why the physicians who treat these patients in acute care hospitals (primarily emergency physicians, internists/hospitalists and intensivists) prioritize life-sustaining therapies over relief of burdensome symptoms as the default strategy. Information gaps affect the process of care. These physicians likely assume that a transfer to an acute care facility indicates the (sometimes mistaken) desire for life-sustaining interventions by the patient’s relatives. Transfer decisions are a human endeavour, and thus are subject to error6 especially when personnel worry about blame. While nearly half of all transfers from nursing homes to the ED are for cardiovascular and respiratory problems, 7 key factors influencing decisions to transfer as reported by family physicians include medico-legal concerns, family pressure, the capability of nursing home staff and the physician’s workload.8Even in Ontario, where nursing home residents are legally required to have annually updated instructions about whether transfer to acute care hospitals is indicated, the process only works as well as the nature of the counselling and discussion (which is often perfunctory) that takes place before the patients or their legal substitutes sign that document. In the United States, it is unclear how and whether the rapid uptake of Physician Orders for Life-Sustaining Treatment in nursing homes has affected end-of-life care in AD.9 From an economic and medico-legal perspective, there is no incentive for nursing homes or their staff to manage the acutely ill nursing home patient themselves, and every incentive to transfer care to an ED even when “no transfer” instructions are clearly recorded. The physician who meets the patient for the first time in the ED often lacks familiarity with the patient’s clinical course and his or her family, which coupled with a lack of communication training for these circumstances, inhibits addressing goals of care directly.10Physician workload is also an important factor. In a busy ED, an empathetic conversation that elucidates patients’ goals of care, educates families about the outcomes of care11 and offers the option of prioritizing attention to symptoms takes time and requires a higher cognitive load than ordering tests, intravenous fluids and antibiotics. In addition, the process of acute care, once initiated, may be a contributing factor. Family members see that life-prolonging therapies can be given, making it more difficult for them to decide to forgo disease-directed therapies once started without being overwhelmed by a sense of guilt. Finally, precise prognostication in a patient with AD is fraught with hazards.12 All of these factors play a role, but overall, until the physicians who see patients in the ED acquire the expertise to routinely address goals of care, and experience the rewards and sense of professional fulfillment that can be derived from sparing patients unwanted invasive care, the opportunity to prioritize comfort may not be offered. Those physicians will revert to their comfort zone of checking the electrolytes, obtaining a chest x-ray and urine culture which then results in a discussion that starts by asking families questions like, “Do you want us to treat the hypernatremia?” When phrased that way, few family members (even those who are physicians) are prepared to say “No.”While assessing goals of care for patients with AD may currently be viewed as impractical in the busy ED, perhaps the right models have not been proposed. Complexity has not deterred the rapid response in EDs for patients with acute strokes and ST-elevation myocardial infarctions. One solution may be to develop a separate “emergency palliative care pathway” where the primary task is prioritizing relief of burdensome symptoms and eliciting true preferences.13 thus avoiding stressful lengthy stays in the chaotic ED where patients with AD are often of low priority. Interventions aimed upstream from the ED may include increasing resources for training of nursing home staff along with the provision of decision aids to assist caregivers in the clarification of goals of care prior to transfer to the ED.14Some patients with AD and their families may prefer prioritizing comfort above all else but may not be offered the chance to make that choice. In a survey of elderly hospitalized Canadians, 70% reported wanting to focus on providing comfort rather than life-prolonging treatment, yet 54% of these patients are admitted to intensive care units at the end of life. 15 Even if this circumstance occurs in a minority of the dementia patients who are sent to EDs, the substantial rise in the number of people with dementia means that it will occur much more commonly in the future. In these cases, emergency physicians and the consultants that they approach for help can play a critical role if they push the pause button before beginning empiric disease-directed therapies, and simply ask patients’ families, “What is your understanding of your loved one’s prognosis?” and, “ What are you hoping for?” On the one hand, these conversations take time. On the other, they can be efficient, focus on these simple questions, and describe outcomes of care including potential discomforts associated with treatments. By shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment, they may alter the trajectory of care, ultimately reducing the burden to patients and their families. We can facilitate patients’ wishes and honour the truly vital role that family members play as members of the health care team.Returning to the case, after a 7-minute discussion of the goals and options for care, led by the internist, the patient’s daughters were unable to decide upon the best course of treatment. A phone call to his wife was made, and she indicated that comfort measures were “what he would want.” After initiating oxygen and subcutaneous morphine for relief of pain and dyspnea in the ED, the patient was transferred to the ward with palliative care physicians. He received comfort-directed care and died peacefully 4 days later surrounded by his family. Competing InterestsNone declared AcknowledgementsWe thank S. Ryan Greysen MD, Gurpreet Dhaliwal (both of University of California San Francisco), Lewis A. Lipsitz MD (Harvard), Howard Ovens MD and Barry J. Goldlist MD (both of University of Toronto) for comments on an earlier draft.References1. Alzheimer Society of Canada. Report summary Prevalence and monetary costs of dementia in Canada (2016): a report by the Alzheimer Society of Canada. Health promotion and chronic disease prevention in Canada: research, policy and practice. October 2016:231–32.2. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000;284(1):47–52.3. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of AD. N Engl J Med 2009;361(16):1529–38. doi:10.1056/NEJMoa0902234.4. Chang A, Walter LC. Recognizing dementia as a terminal illness in nursing home residents: Comment on "Survival and comfort after treatment of pneumonia in AD." Arch Intern Med 2010;170(13):1107–1109. doi:10.1001/archinternmed.2010.166.5. Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med 2011;365(13):1212–21. doi:10.1056/NEJMsa1100347.6. Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. Emergency department use by nursing home residents: effect of severity of cognitive impairment. Gerontologist 2012;52(3):383–93. doi:10.1093/geront/gnr109.7. Jensen PM, Fraser F, Shankardass K, Epstein R, Khera J. Are long-term care residents referred appropriately to hospital emergency departments? Can Fam Physician 2009;55(5):500–505.8. McDermott C, Coppin R, Little P, Leydon G. Hospital admissions from nursing homes: a qualitative study of GP decision making. Br J Gen Pract 2012;62(601):e538–e545. doi:10.3399/bjgp12X653589.9. Halpern SD. Toward evidence-based end-of-life care. N Engl J Med 2015;373(21):2001-2003. doi:10.1056/NEJMp1509664.10. Lamba S, Nagurka R, Zielinski A, Scott SR. Palliative care provision in the emergency department: barriers reported by emergency physicians. J Palliat Med 2013;16(2):143–47. doi:10.1089/jpm.2012.0402.11. Givens JL, Jones RN, Shaffer ML, et al. Survival and comfort after treatment of pneumonia in AD. Arch Intern Med 2010;170(13):1102–107. doi:10.1001/archinternmed.2010.181.12. Mitchell SL, Miller SC, Teno JM, et al. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA 2010;304(17):1929–35. doi:10.1001/jama.2010.1572.13. Grudzen CR, Stone SC, Morrison RS. The palliative care model for emergency department patients with advanced illness. J Palliat Med 2011;14(8):945–50. doi:10.1089/jpm.2011.0011.14. Hanson LC, Zimmerman S, Song M-K, et al. Effect of the goals of care intervention for AD. JAMA Intern Med 2017;177(1):24–28. doi:10.1001/jamainternmed.2016.7031.15. Fowler R, Hammer M. End-of-life care in Canada. Clin Invest Med 2013;36(3):E127–E132.

IntroductionLike other forms of embodiment, pregnancy has increasingly become subject to representation and interpretation via digital technologies. Pregnancy and the unborn entity were largely private, and few people beyond the pregnant women herself had access to the foetus growing within her (Duden). Now pregnant and foetal bodies have become open to public portrayal and display (Lupton The Social Worlds of the Unborn). A plethora of online materials – websites depicting the unborn entity from the moment of conception, amateur YouTube videos of births, social media postings of ultrasounds and self-taken photos (‘selfies’) showing changes in pregnant bellies, and so on – now ensure the documentation of pregnant and unborn bodies in extensive detail, rendering them open to other people’s scrutiny. Other recent digital technologies directed at pregnancy include mobile software applications, or ‘apps’. In this article, we draw on our study involving a critical discourse analysis of a corpus of pregnancy-related apps offered in the two major app stores. In so doing, we discuss the ways in which pregnancy-related apps portray pregnant and unborn bodies. We place a particular focus on the ludification and gamification strategies employed to position pregnancy as a playful, creative and fulfilling experience that is frequently focused on consumption. As we will demonstrate, these strategies have wider implications for concepts of pregnant and foetal embodiment and subjectivity.It is important here to make a distinction between ludification and gamification. Ludification is a broader term than gamification. It is used in the academic literature on gaming (sometimes referred to as ‘ludology’) to refer to elements of games reaching into other aspects of life beyond leisure pursuits (Frissen et al. Playful Identities: The Ludification of Digital Media Cultures; Raessens). Frissen et al. (Frissen et al. "Homo Ludens 2.0: Play, Media and Identity") for example, claim that even serious pursuits such as work, politics, education and warfare have been subjected to ludification. They note that digital technologies in general tend to incorporate ludic dimensions. Gamification has been described as ‘the use of game design elements in non-game contexts’ (Deterding et al. 9). The term originated in the digital media industry to describe the incorporation of features into digital technologies that not explicitly designed as games, such as competition, badges, rewards and fun that engaged and motivated users to make them more enjoyable to use. Gamification is now often used in literatures on marketing strategies, persuasive computing or behaviour modification. It is an important element of ‘nudge’, an approach to behaviour change that involves persuasion over coercion (Jones, Pykett and Whitehead). Gamification thus differs from ludification in that the former involves applying ludic principles for reasons other than the pleasures of enjoying the game for their own sake, often to achieve objectives set by actors and agencies other than the gamer. Indeed, this is why gamification software has been described by Bogost (Bogost) as ‘exploitationware’. Analysing Pregnancy AppsMobile apps have become an important medium in contemporary digital technology use. As of May 2015, 1.5 million apps were available to download on Google Play while 1.4 million were available in the Apple App Store (Statista). Apps related to pregnancy are a popular item in app stores, frequently appearing on the Apple App Store’s list of most-downloaded apps. Google Play’s figures show that many apps directed at pregnant women have been downloaded hundreds of thousands, or even millions, of times. For example, ‘Pregnancy +’, ‘I’m Expecting - Pregnancy App’ and ‘What to Expect - Pregnancy Tracker’ have each been downloaded between one and five million times, while ‘My Pregnancy Today’ has received between five and ten million downloads. Pregnancy games for young girls are also popular. Google Play figures show that the ‘Pregnant Emergency Doctor’ game, for example, has received between one and five million downloads. Research has found that pregnant women commonly download pregnancy-related apps and find them useful sources of information and support (Hearn, Miller and Fletcher; Rodger et al.; Kraschnewski et al.; Declercq et al.; Derbyshire and Dancey; O'Higgins et al.). We conducted a comprehensive analysis of all pregnancy-related smartphone apps in the two major app stores, Apple App Store and Google Play, in late June 2015. Android and Apple’s iOS have a combined market share of 91 percent of apps installed on mobile phones (Seneviratne et al.). A search for all pregnancy-related apps offered in these stores used key terms such as pregnancy, childbirth, conception, foetus/fetus and baby. After eliminating apps listed in these searches that were clearly not human pregnancy-related, 665 apps on Google Play and 1,141 on the Apple App Store remained for inclusion in our study. (Many of these apps were shared across the stores.)We carried out a critical discourse analysis of these apps, looking closely at the app descriptions offered in the two stores. We adopted the perspective that sees apps, like any other form of media, as sociocultural artefacts that both draw on and reproduce shared norms, ideals, knowledges and beliefs (Lupton "Quantified Sex: A Critical Analysis of Sexual and Reproductive Self-Tracking Using Apps"; Millington "Smartphone Apps and the Mobile Privatization of Health and Fitness"; Lupton "Apps as Artefacts: Towards a Critical Perspective on Mobile Health and Medical Apps"). In undertaking our analysis of the app descriptions in our corpus, attention was paid to the title of each app, the textual accounts of its content and use and the images that were employed, such as the logo of the app and the screenshots that were used to illustrate its content and style. Our focus in this article is on the apps that we considered as including elements of entertainment. Pregnancy-related game apps were by far the largest category of the apps in our corpus. These included games for young girls and expectant fathers as well as apps for ultrasound manipulation, pregnancy pranks, foetal sex prediction, choosing baby names, and quizzes. Less obviously, many other apps included in our analysis offered some elements of gamification and ludification, and these were considered in our analysis. ‘Pregnant Adventures’: App Games for GirlsOne of the major genres of apps that we identified was games directed at young girls. These apps invited users to shop for clothes, dress up, give a new hair style, ‘make-over’ and otherwise beautify a pregnant woman. These activities were directed at the goal of improving the physical attractiveness and therefore (it was suggested) the confidence of the woman, who was presented as struggling with coming to terms with changes in her body during pregnancy. Other apps for this target group involved the player assuming the role of a doctor in conducting medical treatments for injured pregnant women or assisting the birth of her baby.Many of these games represented the pregnant woman visually as looking like an archetypal Barbie doll, with a wardrobe to match. One app (‘Barbara Pregnancy Shopping’) even uses the name ‘Barbara’ and the screenshots show a woman similar in appearance to the doll. Its description urges players to use the game to ‘cheer up’ an ‘unconfident’ Barbara by taking her on a ‘shopping spree’ for new, glamorous clothes ‘to make Barbara feel beautiful throughout her pregnancy’. Players may find ‘sparkly accessories’ as well for Barbara and help her find a new hairstyle so that she ‘can be her fashionable self again’ and ‘feel prepared to welcome her baby!’. Likewise, the game ‘Pregnant Mommy Makeover Spa’ involves players selecting clothes, applying beauty treatments and makeup and adding accessories to give a makeover to ‘Pregnant Princess’ Leila. The ‘Celebrity Mommy’s Newborn Baby Doctor’ game combines the drawcard of ‘celebrity’ with ‘mommy’. Players are invited to ‘join the celebrities in their pregnancy adventure!’ and ‘take care of Celebrity Mom during her pregnancy!’.An app by the same developer of ‘Barbara Pregnancy Shopping’ also offers ‘Barbara’s Caesarean Birth’. The app description claims that: ‘Of course her poor health doesn’t allow Barbara to give birth to her baby herself.’ It is up to players to ‘make everything perfect’ for Barbara’s caesarean birth. The screenshots show Barbara’s pregnant abdomen being slit open, retracted and a rosy, totally clean infant extracted from the incision, complete with blonde hair. Players then sew up the wound. A final screenshot displays an image of a smiling Barbara standing holding her sleeping, swaddled baby, with the words ‘You win’.Similar games involve princesses, mermaids, fairies and even monster and vampire pregnant women giving birth either vaginally or by caesarean. Despite their preternatural status, the monster and vampire women conform to the same aesthetic as the other pregnant women in these games: usually with long hair and pretty, made-up faces, wearing fashionable clothing even on the operating table. Their newborn infants are similarly uniform in their appearance as they emerge from the uterus. They are white-skinned, clean and cherubic (described in ‘Mommy’s Newborn Baby Princess’ as ‘the cutest baby you probably want’), a far cry from the squalling, squashed-faced infants smeared in birth fluids produced by the real birth process.In these pregnancy games for girls, the pain and intense bodily effort of birthing and the messiness produced by the blood and other body fluids inherent to the process of labour and birth are completely missing. The fact that caesarean birth is a major abdominal surgery requiring weeks of recovery is obviated in these games. Apart from the monsters and vampires, who may have green- or blue-hued skin, nearly all other pregnant women are portrayed as white-skinned, young, wearing makeup and slim, conforming to conventional stereotypical notions of female beauty. In these apps, the labouring women remain glamorous, usually smiling, calm and unsullied by the visceral nature of birth.‘Track Your Pregnancy Day by Day’: Self-Monitoring and Gamified PregnancyElements of gamification were evident in a large number of the apps in our corpus, including many apps that invite pregnant users to engage in self-tracking of their bodies and that of their foetuses. Users are asked to customise the apps to document their changing bodies and track their foetus’ development as part of reproducing the discourse of the miraculous nature of pregnancy and promoting the pleasures of self-tracking and self-transformation from pregnant woman to mother. When using the ‘Pregnancy+’ app, for example, users can choose to construct a ‘Personal Dashboard’ that includes details of their pregnancy. They can input their photograph, first name and their expected date of delivery so that that each daily update begins with ‘Hello [name of user], you are [ ] weeks and [ ] days pregnant’ with the users’ photograph attached to the message. The woman’s weight gain over time and a foetal kick counter are also included in this app. It provides various ways for users to mark the passage of time, observe the ways in which their foetuses change and move week by week and monitor changes in their bodies. According to the app description for ‘My Pregnancy Today’, using such features allows a pregnant woman to: ‘Track your pregnancy day by day.’ Other apps encourage women to track such aspects of physical activity, vitamin and fluid intake, diet, mood and symptoms. The capacity to visually document the pregnant user’s body is also a feature of several apps. The ‘Baby Bump Pregnancy’, ‘WebMD Pregnancy’, ‘I’m Expecting’,’iPregnant’ and ‘My Pregnancy Today’ apps, for example, all offer an album feature for pregnant bump photos taken by the user of herself (described as a ‘bumpie’ in the blurb for ‘My Pregnancy Today’). ‘Baby Buddy’ encourages women to create a pregnant avatar of themselves (looking glamorous, well-dressed and happy). Some apps even advise users on how they should feel. As a screenshot from ‘Pregnancy Tracker Week by Week’ claims: ‘Victoria, your baby is growing in your body. You should be the happiest woman in the world.’Just as pregnancy games for little girls portrayal pregnancy as a commodified and asetheticised experience, the apps directed at pregnant women themselves tend to shy away from discomforting fleshly realities of pregnant and birthing embodiment. Pregnancy is represented as an enjoyable and fashionable state of embodiment: albeit one that requires constant self-surveillance and vigilance.‘Hello Mommy!’: The Personalisation and Aestheticisation of the FoetusA dominant feature of pregnancy-related apps is the representation of the foetus as already a communicative person in its own right. For example, the ‘Pregnancy Tickers – Widget’ app features the image of a foetus (looking far more like an infant, with a full head of wavy hair and open eyes) holding a pencil and marking a tally on the walls of the uterus. The app is designed to provide various icons showing the progress of the user’s pregnancy each day on her mobile device. The ‘Hi Mommy’ app features a cartoon-like pink and cuddly foetus looking very baby-like addressing its mother from the womb, as in the following message that appears on the user’s smartphone: ‘Hi Mommy! When will I see you for the first time?’ Several pregnancy-tracking apps also allow women to input the name that they have chosen for their expected baby, to receive customised notifications of its progress (‘Justin is nine weeks and two days old today’).Many apps also incorporate images of foetuses that represent them as wondrous entities, adopting the visual style of 1960s foetal photography pioneer Lennart Nilsson, or what Stormer (Stormer) has referred to as ‘prenatal sublimity’. The ‘Pregnancy+’ app features such images. Users can choose to view foetal development week-by-week as a colourful computerised animation or 2D and 3D ultrasound scans that have been digitally manipulated to render them aesthetically appealing. These images replicate the softly pink, glowing portrayals of miraculous unborn life typical of Nilsson’s style.Other apps adopt a more contemporary aesthetic and allow parents to store and manipulate images of their foetal ultrasounds and then share them via social media. The ‘Pimp My Ultrasound’ app, for example, invites prospective parents to manipulate images of their foetal ultrasounds by adding in novelty features to the foetal image such as baseball caps, jewellery, credit cards and musical instruments. The ‘Hello Mom’ app creates a ‘fetal album’ of ultrasounds taken of the user’s foetus, while the ‘Ultrasound Viewer’ app lets users manipulate their 3/4 D foetal ultrasound images: ‘Have fun viewing it from every angle, rotating, panning and zooming to see your babies [sic] features and share with your family and friends via Facebook and Twitter! … Once uploaded, you can customise your scan with a background colour and skin colour of your choice’.DiscussionPregnancy, like any other form of embodiment, is performative. Pregnant women are expected to conform to norms and assumptions about their physical appearance and deportment of their bodies that expect them to remain well-groomed, fit and physically attractive without appearing overly sexual (Longhurst "(Ad)Dressing Pregnant Bodies in New Zealand: Clothing, Fashion, Subjectivities and Spatialities"; Longhurst "'Corporeographies’ of Pregnancy: ‘Bikini Babes'"; Nash; Littler). Simultaneously they must negotiate the burden of bodily management in the interests of risk regulation. They are expected to protect their vulnerable unborn from potential dangers by stringently disciplining their bodies and policing to what substances they allow entry (Lupton The Social Worlds of the Unborn; Lupton "'Precious Cargo': Risk and Reproductive Citizenship"). Pregnancy self-tracking apps enact the soft politics of algorithmic authority, encouraging people to conform to expectations of self-responsibility and self-management by devoting attention to monitoring their bodies and acting on the data that they generate (Whitson; Millington "Amusing Ourselves to Life: Fitness Consumerism and the Birth of Bio-Games"; Lupton The Quantified Self: A Sociology of Self-Tracking).Many commentators have remarked on the sexism inherent in digital games (e.g. Dickerman, Christensen and Kerl-McClain; Thornham). Very little research has been conducted specifically on the gendered nature of app games. However our analysis suggests that, at least in relation to the pregnant woman, reductionist heteronormative, cisgendered, patronising and paternalistic stereotypes abound. In the games for girls, pregnant women are ideally young, heterosexual, partnered, attractive, slim and well-groomed, before, during and after birth. In self-tracking apps, pregnant women are portrayed as ideally self-responsible, enthused about their pregnancy and foetus to the point that they are counting the days until the birth and enthusiastic about collecting and sharing details about themselves and their unborn (often via social media).Ambivalence about pregnancy, the foetus or impending motherhood, and lack of interest in monitoring the pregnancy or sharing details of it with others are not accommodated, acknowledged or expected by these apps. Acknowledgement of the possibility of pregnant women who are not overtly positive about their pregnancy or lack interest in it or who identify as transgender or lesbian or who are sole mothers is distinctly absent.Common practices we noted in apps – such as giving foetuses names before birth and representing them as verbally communicating with their mothers from inside the womb – underpin a growing intensification around the notion of the unborn entity as already an infant and social actor in its own right. These practices have significant implications for political agendas around the treatment of pregnant women in terms of their protection or otherwise of their unborn, and for debates about women’s reproductive rights and access to abortion (Lupton The Social Worlds of the Unborn; Taylor The Public Life of the Fetal Sonogram: Technology, Consumption and the Politics of Reproduction). Further, the gamification and ludification of pregnancy serve to further commodify the experience of pregnancy and childbirth, contributing to an already highly commercialised environment in which expectant parents, and particularly mothers, are invited to purchase many goods and services related to pregnancy and early parenthood (Taylor "Of Sonograms and Baby Prams: Prenatal Diagnosis, Pregnancy, and Consumption"; Kroløkke; Thomson et al.; Taylor The Public Life of the Fetal Sonogram: Technology, Consumption and the Politics of Reproduction; Thomas).In the games for girls we examined, the pregnant woman herself was a commodity, a selling point for the app. The foetus was also frequently commodified in its representation as an aestheticised entity and the employment of its image (either as an ultrasound or other visual representations) or identity to market apps such as the girls’ games, apps for manipulating ultrasound images, games for predicting the foetus’ sex and choosing its name, and prank apps using fake ultrasounds purporting to reveal a foetus inside a person’s body. As the pregnant user engages in apps, she becomes a commodity in yet another way: the generator of personal data that are marketable in themselves. In this era of the digital data knowledge economy, the personal information about people gathered from their online interactions and content creation has become highly profitable for third parties (Andrejevic; van Dijck). Given that pregnant women are usually in the market for many new goods and services, their personal data is a key target for data mining companies, who harvest it to sell to advertisers (Marwick).To conclude, our analysis suggests that gamification and ludification strategies directed at pregnancy and childbirth can serve to obfuscate the societal pressures that expect and seek to motivate pregnant women to maintain physical fitness and attractiveness, simultaneously ensuring that they protect their foetuses from all possible risks. In achieving both ends, women are encouraged to engage in intense self-monitoring and regulation of their bodies. These apps also reproduce concepts of the unborn entity as a precious and beautiful already-human. These types of portrayals have important implications for how young girls learn about pregnancy and childbirth, for pregnant women’s experiences and for concepts of foetal personhood that in turn may influence women’s reproductive rights and abortion politics.ReferencesAndrejevic, Mark. Infoglut: How Too Much Information Is Changing the Way We Think and Know. New York: Routledge, 2013. Print.Bogost, Ian. "Why Gamification Is Bullshit." The Gameful World: Approaches, Issues, Applications. Eds. Steffen Walz and Sebastian Deterding. Boston, MA: MIT Press, 2015. 65-80. Print.Declercq, E.R., et al. Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection, 2013. Print.Derbyshire, Emma, and Darren Dancey. 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Jessica craned her head to take in the imposing, stone building, then lowered her gaze to the gold-plated sign at the base of the steps. “Institute of Methodology”, it read. Inside the heavy iron doors, a woman sat at a desk, her face devoid of expression. “Subject area?” asked the woman. “Uhmm, feminism ... and fiction, I think.” “Turn right.” “Do you have a map?” “No.” “How am I meant to find things?” “Each has their own method; it’s not up to us to prescribe that.” Jessica sighed, readjusted her handbag and turned right. A corridor stretched out before her. She set off, her stiletto boots echoing on the hard wooden floor. The first door she arrived at had the words “Deleuze and Guattari” positioned squarely in the middle. She hesitated, then turned the doorknob. The room was white and empty. A male voice issued from somewhere but she couldn’t tell the direction from which it came. It droned on, with some inflection, but there was no way of knowing where the sentences started and finished. She picked out a few words: a thousand plateaus, becoming, burrowing, but couldn’t piece them into anything meaningful. She backed out of the room, frowning, and asked me, How am I going to learn anything if they only have these voices? I can’t lipread them. And how can I produce something factual if I haven’t heard it all? I might make stuff up. You always make things up anyway. After the barrier of disembodied sound, the silence of the corridor was soothing. Jessica always had difficulty with hearing men’s voices, for their registers were lower. Sometimes, she wondered if this was the reason she’d become interested in feminism: women were simply easier to understand. The next door was labelled “Facets of Phenomenology.” After that was “Post-It Notes and Poststructuralism”, “Interpretation of Geometric Design”, “Knitting Class” and “Cyberspace and Geography.” None of these were very helpful. She wanted something on bodies and writing. She walked on. It was, she soon realised, so terribly easy to lose one’s way. The corridors continued. She turned right most of the time, and occasionally left. Her arches began to ache. After a while she came to the conclusion that she had no idea of where she was. Immediately, a bird appeared and dived down her throat. Trapped, it thudded against her ribs. Breathe, I told her. Breathe. She put a hand out to the wall. Outside another door she heard, a voice with a distinct Australian accent. She checked the label on the door. “Fictocriticism,” it read. The door opened. The bird climbed out of her chest and flew away. A young woman stood before her, wearing bright red lipstick. “We saw your shadow beneath the door.” She pointed to Jessica’s feet. “We don’t like barriers, so come in.” The room was airy and brilliantly lit, with a high ceiling patterned with pressed metal vines and flowers. A man and a handful of women sat at a table covered with papers, bottles of wine, brie, sundried tomatoes and crackers. “Wine?” asked the woman, a bottle in her hand. “It’s from Margaret River.” “Oh yes, please.” Jessica pulled out a chair from the table. The people’s faces looked friendly. “What brings you here?” The woman with red lipstick asked, handing her a glass. “I’m trying to find a writing style that’s comfortable for me to use. I just can’t relate to abstract texts, like those by Deleuze and Guattari.” Jessica eyed the cheese platter on the table. She was hungry. “Help yourself,” said the man. Jessica picked up the cheese knife and a cracker. “You’d like my essay, then, ‘Me and My Shadow.’” It was an older woman speaking, with soft grey hair and luminous eyes. “In it I assert that Guattari’s Molecular Revolution is distancing and, she pushed the pile of paper napkins towards Jessica, ‘totally abstract and impersonal. Though the author uses the first person (‘The distinction I am proposing’, ‘I want therefore to make it clear’), it quickly became clear to me that he had no interest whatsoever in the personal, or in concrete situations as I understand them – a specific person, a specific machine, somewhere in time and space, with something on his/her mind, real noises, smells, aches and pains” (131). Jessica thought about the first room, where Deleuze’s and Guattari’s voices had seemed to issue from nowhere. “Of course,” she said. “If my comprehension comes from reading faces and bodies, it follows that those writers who evince themselves in the text will be the ones that appeal to me.” The rest of the table was silent. “I’m deaf,” Jessica explained. “I’ve no hearing in my left ear and half in my right, but people don’t know until I tell them.” “I’d never have guessed,” said the woman with red lipstick. “I’m good at faking it,” Jessica replied wryly. “It seems to me that, if I only hear some things and make the rest up, then my writing should reflect that.” “We might be able to help you — we write about, and in the style of, fictocriticism.” Two women were talking at once. It was difficult to tell who was saying what. “But what is it?” Jessica asked. “That’s a problematic question. It resists definition, you see, for the form it takes varies according to the writer.” She glanced from one woman to the other. It was hard to keep up. They went on, “Fictocriticism might most usefully be defined as hybridised writing that moves between the poles of fiction (‘invention’/‘speculation’) and criticism (‘deduction’/‘explication’), of subjectivity (‘interiority’) and objectivity (‘exteriority’). It is writing that brings the ‘creative’ and the ‘critical’ together – not simply in the sense of placing them side by side, but in the sense of mutating both, of bringing a spotlight to bear upon the known forms in order to make them ‘say’ something else” (Kerr and Nettlebeck 3). “It began to incorporate narratives and styles that wrote against omniscience in favour of fragmentary, personal perspectives.” Concentrating on cutting and spreading her brie, Jessica couldn’t see who had said this. She looked up, trying to see who had spoken. “In addition,” said a young, slim woman, “The use of autobiographical elements in ficto-criticism that include the body and personal details … realises a subjectivity that is quite different from the controlling academic critical subject with their voice from on high” (Flavell 77). Jessica bit into her cracker. The brie was creamy, but rather too strong. She piled sundried tomatoes onto it. “It is of course, a capacious category,” the man added, “as it must be if it is inspired by the materials and situation at hand. One might urge the interested writer not to feel that their practice has to conform to one or another model, but to have the confidence that the problem characterising the situation before them will surprise them into changing their practices. Like all literature, fictocriticism experiments with ways of being in the world, with forms of subjectivity if you like” (Muecke 15). Jessica nodded, her mouth full of biscuit and brie. Oil dripped from the tomatoes down her fingers. “Yes,” it was the two women in their duet, “in fictocritical writings the ‘distance’ of the theorist/critic collides with the ‘interiority’ of the author. In other words, the identity of the author is very much at issue. This is not to say that an ‘identity’ declares itself strictly in terms of the lived experience of the individual, but it does declare itself as a politic to be viewed, reviewed, contested, and above all engaged with” (Kerr and Nettlebeck 3). “That makes sense,” Jessica thought aloud. “Everything I write is an amalgam of fact and fiction, because I hear some things and make the rest up. Deafness influences the way I process and write about the world, so it seems I can’t avoid my body when I write.” She lifted a napkin from the pile and wiped her oily fingers. “Yet, to use a language of the body, or écriture féminine, is also to run the risk of essentialism, of assuming that, for example when we write long, silky sentences, we are saying that this is how every woman would write. It’s also true that, when writing, we don’t have to be limited to our own bodies – we can go beyond them.” She paused, thinking. “It’s been said that sign language is a form of écriture féminine, for a person who signs literally writes with their hands. Where are my notes?” She ferreted through her handbag, pushing aside tubes of lip gloss and hand cream, a bus pass and mirror, and extracted some folded pieces of paper. “Here, H-Dirksen L. Bauman comments on the possibilites of écriture féminine for the disabled, writing that, The project of recognizing Deaf identity bears similarities to the feminist project of re-gaining a ‘body of one’s own’ through linguistic and literary practices. Sign, in a more graphic way, perhaps, than l’écriture féminine is a ‘writing of/on the body.’ The relation between Sign and l’écriture féminine raises questions that could have interesting implications for feminist performance. Does the antiphonocetric nature of Sign offer a means of averting these essentializing tendency of l’écriture féminine? Does the four-dimensional space of performance offer ways of deconstructing phallogocentric linear discourse? (359) “As Sign is a writing by the body, it could be argued that each body produces an original language. I think it’s this, rather than antiphonocentrism — that is, refusing to privilege speech over writing, as has been the tradition — that represents the destabilising effects of Sign.” “Here’s Jamming the Machinery.” The slim woman pushed a book towards Jessica. “It’s about contemporary Australian écriture féminine.” Jessica opened the covers and began reading: As a counter-strategy, écriture féminine, it is argued, is theoretically sourced in the bodies of women. Here, the body represents one aspect of what it ‘means’ to be a woman, but of course our bodies are infinitely variable as are our socio-historical relations and the way that we live through and make meaning of our particular bodies. Texts, however, are produced through the lived practices of being socially positioned as (among other things) women, so those effects will be inscribed in actively inventing ways for women to speak and write about ourselves as women, rather than through the narrative machinery of patriarchy (Bartlett 1-2). I agree with that, Jessica mused to herself. Even if, on paper, écriture féminine does run the risk of essentialism, it’s still a useful strategy, so long as one remains attentive to the specificity of each individual body. She looked up. The conversation was becoming loud, joyful and boisterous. It was turning into a party. Sadly, she stood. “I’d like to stay, but I have to keep thinking.” She pushed in her chair. “Thank you for your ideas.” “Goodbye and good luck!” they chorused, and replenished their wine glasses. Outside, it was getting dark. She trailed her fingers along the wall for balance. Her sight orientated her; without it, she was liable to fall over, particularly in stilettos. Seeing a movement near the ceiling, Jessica stopped and peered upwards. Dragons! she cried. Sitting in the rafters were three small, pearly white dragons, their scaly hides gleaming in the darkness. Here, she called, stretching out a hand. One dropped, swooping, and landed on her wrist, its talons gripping her arm. Ouch! It looked at her curiously with its small gold eyes, then stretched its wings proudly. Dark blue veins ran across the soft membrane. You’re not very cuddly, she told it, but you are exquisite. Tell me, are you real? For an answer, it leaned over and gently nipped her thumb, drawing blood. Its tail swished like a cat’s in a frisky mood. Stop making things up, I scolded her. This is supposed to be serious. Abruptly, the dragon sprang from her wrist, winging gracefully back to the ceiling. Jessica rubbed her arm and continued, feeling ripples of unevenly applied paint beneath her fingertips. Let me pose a question, I suggested: if a fairy godmother offered you your hearing, would you take it? Well, deafness has made me who I am— You mean, an opinionated, obnoxious, feminist thinker and writer? Yes, exactly. So perhaps I wouldn’t take it. And where would you be without silence, which has given you the space in which to think, and which has shaped you as a writer? Without silence, you wouldn’t have turned to words. Hmmm, yes. She slowed. It’s awfully dark in here now. And quiet. For deaf people, silence has often been yoked together with negative connotations – it’s a cave, a prison, a tomb. Sometimes it can feel like this, but, as you know, at other times it’s liberating. You don’t have to listen to someone yakking on their mobile phone on the bus, nor overhear your flatmate having loud sex in the room above; you can simply switch off your hearing aid and keep reading your book, or thinking your thoughts. In a somewhat similar situation, Stephen Hawking, the theoretical physicist, has said that ‘his disability has given him the advantage of having more time to think,’ although Susan Wendell points out that he is only able to do this ‘because of the help of his family, three nurses, a graduate student who travels with him to maintain his computer-communications systems’ – resources which are unavailable to many disabled people” (109). Thus although disability has been largely theorised as lack, it would seem that the contrary is the case: disability brings with it a wealth of possibility. Jessica slowed, feeling vibrations in the wall and beneath our feet. Her heartbeat quickened. Maybe it’s music. It’s not. It’s irregular. Then we heard the sound, like distant thunder. Get back against the wall, I ordered her. Seconds later a crowd of creatures ran past, rattling the floorboards. They were so black we couldn’t see them. What was that? she asked. They smelled like horses. Musky, but sharp too. Let’s get moving. And I told you to stop making things up. I didn’t make that up! she protested. Her pulse was still rapid, so I kept talking to distract her. The difficulty is to avoid referring to the disabled person as having lost something. Of course, you can lose your hearing, but you gain infinitely more in other ways – your senses of touch, taste, smell and sight are augmented. In the current climate of thinking, this is easier said than done. Lennard Davis indicates with distaste that discussions of disability stop theorists in their tracks. Disability, as it has been formulated, is a construct that is defined by lack. Rather than face this ragged imaged [of the disabled individual], the critic turns to the fluids of sexuality, the gloss of lubrication, the glossary of the body as text, the heteroglossia of the intertext, the glossolalia of the schizophrenic. But almost never the body of the differently abled (5). Theorists of disability consistently point out that, if more effort and energy were directed towards the philosophical implications of the disabled body, a wealth of new material and ideas would emerge that would shatter existing presumptions about the corporeal. For example, there are still immense possibilities thrown up by theorising a jouissance, or pleasure, in the disabled body. As Susan Wendell points out, “paraplegics and quadriplegics have revolutionary things to teach us about the possibilities of sexuality which contradict patriarchal culture’s obsessions with the genitals” (120). Thus if there were more of a focus on the positive aspects of disability and on promoting the understanding that disability is not about lack, people could see how it fosters creativity and imagination. Jessica saw with relief that there was a large bay window at the end of a corridor, looking out onto the Institute’s grounds. She collapsed onto the bench beneath it, which was layered with cushions. The last of the sun was fading and the grass refracted a golden sheen. She unzipped her boots and swung her legs onto the bench. Leaning her head back against the wall, she remembered a day at primary school when she was eleven. She sat on the blue seat beneath the Jacaranda tree, a book open in her lap. It was lunchtime, the sun was warm and purple Jacaranda blossoms lay scattered at her feet, some squidged wetly into the cement. She looked up from the book to watch her classmates playing soccer on the field, shouting and calling. She would have joined them, except that of late she had felt awkwardness, where before she had been blithe. She, who was so used to scrambling over the delightful hardness of wool bales in the shearing shed, who ran up and down the banks of creeks and crawled into ti trees, flakes of bark sticking to her jumper, had gradually, insidiously, learnt a consciousness of her body. She was not like them. We were silent. The electric lights on the walls of the building came on, illuminating sections of the stonework. At the time, she hated being isolated, but it forced to look at the world differently. Spending so much time on her own also taught her to listen to me, her imagination, and because of that her writing flourished. There was a flutter in the hallway. The tiny dragon had returned. It braked in the air, circled, and floated gently onto her skirt. Was this your doing? She asked me suspiciously. Maybe. She held out her palm. The dragon jumped into it, squeaking, its tail whipping lazily. Jessica smiled. References Bartlett, Alison. Jamming the Machinery: Contemporary Australian Women’s Writing. Toowoomba: Association for the Study of Australian Literature, 1998. Bauman, H-Dirksen L. “Toward a Poetics of Vision, Space and the Body.” The Disability Studies Reader. Ed. Lennard J. Davis. Hoboken: Routledge, 2006. 355-366. Davis, Lennard J. Enforcing Normalcy: Disability, Deafness, and the Body. London: Verso, 1995. Flavell, Helen. Writing-Between: Australian and Canadian Ficto-Criticism. Ph.D. Thesis. Murdoch University, 2004. Gibbs, Anna. “Writing and the Flesh of Others.” Australian Feminist Studies 18 (2003): 309–319. Kerr, Heather, and Amanda Nettlebeck. “Notes Towards an Introduction.” The Space Between: Australian Women Writing Fictocriticism. Ed. Heather Kerr and Amanda Nettlebeck. Nedlands: U of Western Australia P, 1998. 1-18. Muecke, Stephen. Joe in the Andamans: And Other Fictocritical Stories. Erskineville: Local Consumption Publications, 2008. Tompkins, Jane. “Me and My Shadow.” Gender and Theory: Dialogues on Feminist Criticism. Ed. Linda Kauffman. Oxford: Basil Blackwell, 1989. 121-139. Wendell, Susan. “Towards a Feminist Theory of Disability.” Hypatia 4 (1989): 104–124.