Journal articles on the topic 'United Oxford Hospitals'

A multilocus sequence typing (MLST) scheme has been developed forStaphylococcus aureus. The sequences of internal fragments of seven housekeeping genes were obtained for 155 S. aureusisolates from patients with community-acquired and hospital-acquired invasive disease in the Oxford, United Kingdom, area. Fifty-three different allelic profiles were identified, and 17 of these were represented by at least two isolates. The MLST scheme was highly discriminatory and was validated by showing that pairs of isolates with the same allelic profile produced very similar SmaI restriction fragment patterns by pulsed-field gel electrophoresis. All 22 isolates with the most prevalent allelic profile were methicillin-resistant S. aureus (MRSA) isolates and had allelic profiles identical to that of a reference strain of the epidemic MRSA clone 16 (EMRSA-16). Four MRSA isolates that were identical in allelic profile to the other major epidemic MRSA clone prevalent in British hospitals (clone EMRSA-15) were also identified. The majority of isolates (81%) were methicillin-susceptible S. aureus (MSSA) isolates, and seven MSSA clones included five or more isolates. Three of the MSSA clones included at least five isolates from patients with community-acquired invasive disease and may represent virulent clones with an increased ability to cause disease in otherwise healthy individuals. The most prevalent MSSA clone (17 isolates) was very closely related to EMRSA-16, and the success of the latter clone at causing disease in hospitals may be due to its emergence from a virulent MSSA clone that was already a major cause of invasive disease in both the community and hospital settings. MLST provides an unambiguous method for assigning MRSA and MSSA isolates to known clones or assigning them as novel clones via the Internet.

Aims The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures Methods A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot. Results The mean time from initial trauma to surgery was 10.5 days (1 to 33). Earlier surgical intervention did not improve OSS throughout follow-up, nor when stratified by participant age (< 65 years vs ≥ 65 years) and fracture severity (one- and two-part vs three- and four-part fractures). Participants managed later than reported international averages (three days in the United States and Germany, eight days in the United Kingdom) did not have worse outcomes. At five-year follow-up, 50 participants (76%) had the same or improved OSS compared with six months (six-month mean OSS 35.8 (SD 10.0); five-year mean OSS 40.1 (SD 9.1); r = 0.613). A Bland-Altman plot demonstrated a positive mean difference (3.3 OSS points (SD 7.92)) with wide 95% limits of agreement (-12.2 and 18.8 points). Conclusion Timing of surgery did not affect OSS at any stage of follow-up, irrespective of age or fracture type. Most participants had maximum functional outcome at six months that was maintained at five years. These findings may help guide providers of trauma services on surgical prioritization. Cite this article: Bone Joint J 2020;102-B(1):33–41

ABSTRACT We report on a detailed study on the molecular diversity and evolutionary relationships of Tn1546-like elements in vancomycin-resistant enterococci (VRE) from humans and animals. Restriction fragment length polymorphism (RFLP) analysis of the VanA transposon of 97 VRE revealed seven different Tn1546 types. Subsequent sequencing of the complete VanA transposons of 13 VRE isolates representing the seven RFLP types followed by sequencing of the identified polymorphic regions in 84 other VanA transposons resulted in the identification of 22 different Tn1546derivatives. Differences between the Tn1546 types included point mutations in orf1, vanS,vanA, vanX, and vanY. Moreover, insertions of an IS1216V-IS3-like element inorf1, of IS1251 in the vanS-vanHintergenic region, and of IS1216V in thevanX-vanY intergenic region were found. The presence of insertion sequence elements was often associated with deletions in Tn1546. Identical Tn1546 types were found among isolates from humans and farm animals in The Netherlands, suggesting the sharing of a common vancomycin resistance gene pool. Application of the genetic analysis of Tn1546 to VRE isolates causing infections in hospitals in Oxford, United Kingdom, and Chicago, Ill., suggested the possibility of the horizontal transmission of the vancomycin resistance transposon. The genetic diversity in Tn1546 combined with epidemiological data suggest that the DNA polymorphism among Tn1546 variants can successfully be exploited for the tracing of the routes of transmission of vancomycin resistance genes.

Sir William Osler’s legacy lives on through the Fellowship of Postgraduate Medicine (FPM). Osler was in 1911 founding President both of the Postgraduate Medical Association and on 1981 of the Inter-allied Fellowship of Medicine. These societies merged later in 1919, with Osler as President until his death at the end of that year. This joint organization was initially called the Fellowship of Medicine and Post-Graduate Medical Association and continues to this day as the Fellowship of Postgraduate Medicine. In the 1880s, in his role as medical leader in North America, Osler pioneered hospital residency programmes for junior trainee doctors. As Regius Professor of medicine in Oxford from 1905, Osler wished early postgraduate teaching in the UK, and in London in particular, to include access to ‘the wealth of material at all the hospitals’. He also saw medical societies as important for providing reliable continuous medical develop for senior doctors.Under Osler’s leadership, the Fellowship of Medicine responded to demand for postgraduate civilian medical training after the First World War, supported by a general committee of 73 senior medical figures, with representatives from the British Army Medical Service, Medical Services of the Dominions of the United Kingdom, of America and of the British Colleges and major medical Schools. Some fifty general and specialist hospitals were initially affiliated with the Fellowship, which provided sustained support of postgraduate training well into the 1920s, including publication of a weekly bulletin of clinics, ward rounds, special lectures and organized training courses for men and women of all nationalities. In 1925, in response to expanding interest in postgraduate education, the Fellowship developed the bulletin into the Postgraduate Medical Journal, which continues as a monthly international publication. Stimulated by discussions at meetings of the FPM, through its Fellows, the FPM was influential in encouraging London and regional teaching hospitals to develop and maintain postgraduate training courses. The FPM and its Fellows also were important in supporting the creation of a purely postgraduate medical school, which was eventually founded at the Hammersmith Hospital in West London as the British, then Royal Postgraduate Medical School.At the end of the Second World War, there was a major development in provision of postgraduate medical education with the founding in 1945 of the British Postgraduate Medical Federation, which was supported by government, the University Grants Committee and the universities. There was also a marked post-war increase in general provision of postgraduate training at individual hospitals and within the medical Royal Colleges. Postgraduate Centres were established at many hospitals.Nonetheless the FPM continued some involvement in postgraduate courses until 1975. Since then the FPM has maintained a national and international role in postgraduate education through its journals, the Postgraduate Medical Journal and Health Policy and Technology (founded in 2012) and by affiliations with other organisations and institutes.Osler was an avid supporter of engagement between medicine and the humanities, chiding humanists for ignorance of modern science and fellow scientists for neglecting the humanities. The FPM has over much of the past decade supported this theme of Osler by being a major patron of the Hippocrates Prize for Poetry and Medicine, which has achieved significant international interest, with over 10,000 entries from over 70 countries.

Background:Breast cancer is the most common cancer in Iraq and the United Kingdom. While the disease is frequently diagnosed among middle-aged Iraqi women at advanced stages accounting for the second cause of cancer-related deaths, breast cancer often affects elderly British women yielding the highest survival of all registered malignancies in the UK.Objective:To compare the clinical and pathological profiles of breast cancer among Iraqi and British women; correlating age at diagnosis with the tumor characteristics, receptor-defined biomarkers and phenotype patterns.Methods:This comparative retrospective study included the clinical and pathological characteristics of (1,940) consecutive female patients who were diagnosed with invasive breast cancer from 2014 to 2016 in Iraq (Medical City Teaching Hospital, Baghdad: 635 cases) and UK (John Radcliffe, Oxford and Queen's, BHR University Hospitals: 1,305 cases). The studied parameters in both groups comprised the age of the patient at the time of diagnosis, breast cancer histologic type, grade, tumor size, lymph node status, clinical stage at presentation, Estrogen Receptor (ER), Progesterone Receptor (PR) and HER2 positive tumor contents and the receptor-defined breast cancer surrogate subtypes.Results:The Iraqi patients were significantly younger than their British counterparts and exhibited higher trend to present at advanced stages; reflected by larger size tumors and frequent lymph node involvement compared to the British (p<0.00001). They also had worse receptor-defined breast cancer subtypes manifested by higher rates of hormone receptor (ER/PR) negative, HER2 positive tumor contents, Triple Positive and Triple Negative phenotypes (p<0.00001). Excluding HER2 status, the significant differences in the clinical and tumor characteristics between the two populations persisted after adjusting for age among patients younger than 50 years.Conclusion:The remarkable differences in the clinical and tumor characteristics of breast cancer between the Iraqi and British patients suggest heterogeneity in the underlying biology of the tumor which is exacerbated in Iraq by the dilemma of delayed diagnosis. The significant ethnic disparities in breast cancer profiles recommend the prompt strengthening of the national cancer control plan in Iraq as a principal approach to the management of the disease.

Background: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of complications and death following surgery. Pulmonary complications are particularly prominent. Pulmonary rehabilitation is a course of physical exercise and education that helps people with COPD manage their condition. Although proven to improve health outcomes in patients with stable COPD, it has never been formally tested as a pre-surgical intervention in patients scheduled for non-cardiothoracic surgery. If a beneficial effect were to be demonstrated, pulmonary rehabilitation for pre-surgical patients with COPD might be rapidly implemented across the National Health Service, as pulmonary rehabilitation courses are already well established across much of the United Kingdom (UK). Methods: We performed a feasibility study to test study procedures and barriers to identification and recruitment to a randomised controlled trial testing whether pulmonary rehabilitation, delivered before major abdominal surgery in a population of people with COPD, would reduce the incidence of post-operative pulmonary complications. This study was run in two UK centres (Oxford and Newcastle upon Tyne). Results: We determined that a full randomised controlled trial would not be feasible, due to failure to identify and recruit participants. We identified an unmet need to identify more effectively patients with COPD earlier in the surgical pathway. Service evaluations suggested that barriers to identification and recruitment would likely be the same across other UK hospitals. Conclusions: Although pulmonary rehabilitation is a potentially beneficial intervention to prevent post-operative pulmonary complications, a randomised controlled trial is unlikely to recruit sufficient participants to answer our study question conclusively at the present time, when spirometry is not automatically conducted in all patients planned for surgery. As pulmonary rehabilitation is a recommended treatment for all people with COPD, alternative study methods combined with earlier identification of candidate patients in the surgical pathway should be considered. Trial registration: ISRCTN29696295, 31/08/2017

Abstract The 2017 European LeukemiaNet 2017 acute myeloid leukemia (AML) risk stratification (ELN2017) is widely used for risk-stratifying patients with AML. However, its applicability in low- and middle-income countries is limited because of a lack of full cytogenetic and molecular information at diagnosis. Here, we propose an alternative for risk stratification (the Adapted Genetic Risk [AGR]), which permits cytogenetic or molecular missing data while retaining prognostic power. We first analyzed 167 intensively treated patients with nonacute promyelocytic leukemia AML enrolled in São Paulo, Brazil (Faculdade de Medicina da Universidade de São Paulo), as our training data set, using ELN2017 as the standard for comparison with our AGR. Next, we combined our AGR with clinical prognostic parameters found in a Cox proportional hazards model to create a novel scoring system (survival AML score, SAMLS) that stratifies patients with newly diagnosed AML. Finally, we have used 2 independent test cohorts, Faculdade de Medicina de Ribeirão Preto (FMRP; Brazil, n = 145) and Oxford University Hospitals (OUH; United Kingdom, n = 157) for validating our findings. AGR was statistically significant for overall survival (OS) in both test cohorts (FMRP, P = .037; OUH, P = .012) and disease-free survival in FMRP (P = .04). The clinical prognostic features in SAMLS were age (&gt;45 years), white blood cell count (&lt;1.5 or &gt;30.0 × 103/μL), and low albumin levels (&lt;3.8 g/dL), which were associated with worse OS in all 3 cohorts. SAMLS showed a significant difference in OS in the training cohort (P &lt; .001) and test cohorts (FMRP, P = .0018; OUH, P &lt; .001). Therefore, SAMLS, which incorporates the novel AGR evaluation with clinical parameters, is an accurate tool for AML risk assessment.

Since graduating from medical school eight years ago, I have had the chance of experiencing clinical psychiatry in four countries on four continents; Bombay and Goa, India, my home, where I trained in medicine and began my psychiatric training; Oxford and London, United Kingdom, where I acquired a taste for academic psychiatry and completed my clinical training; Sydney, Australia, where I worked in a liaison unit in a large general hospital and a community mental health centre; and now, Harare, Zimbabwe, where I am conducting a two year study on traditional concepts of mental illness and the role of traditional healers and other care providers in primary mental health care.

Purpose: To date there are no United Kingdom (UK) studies specifically evaluating handovers amongst core surgical trainees (CSTs). The Oxford School of Surgery examined regional handover practice, aiming to assess and improve trainee perception of handover, its quality, and ultimately patient care. Methods: Based on two guidance documents ('Safe handover, safe patients' by the British Medical Association and 'Safe Surgical Practice' by the Royal College of Surgeons'), a 5-point Likert style questionnaire was designed, exploring handover practice, educational value, and satisfaction. This was given to 50 CSTs in 2010.Results: There were responses from 40 CSTs (80.0 %). The most striking findings revolved around perceived educational value, formal training, and auditing practice with regards to handover, which were all remarkably lower than expected. CST handover was thus targeted in the Department of Plastic Surgery at the University Hospital, with the suggestion and implementation of targeted changes to improve practice. Conclusion: In the EWTD era with many missed educational opportunities, daily handover represents an underused educational tool for CSTs, especially in light of competency-based and time-limited training. We recommend modifications based on our results and the literature and hope schools of surgery follow suit nationally by assessing and addressing handover practice.

Category: Ankle, Ankle Arthritis Introduction/Purpose: The Infinity (Wright medical) total ankle replacement (TAR) has become the most implanted ankle replacement in the UK with a 30.1% share in the most recent 2016 England and Wales NJR 14th report. It is a fixed bearing implant utilising an anterior approach and radiological guidance to aid alignment, and is approved for use in the UK as an uncemented implant. Methods: Since introducing the Infinity TAR in June 2014, all implants from two centres in the UK; The Royal Devon and Exeter Hospital NHS Foundation Trust and Northumbria NHS Healthcare Trust, have been followed up prospectively. 113 implants are included with 2 year minimum follow-up, average follow-up being 33 months (24-52). Pre- and post-operative demographic, radiographic and functional outcomes were collected including Visual Analogue Score (VAS), Manchester Oxford foot questionnaire (MOxFQ, UK validated patient reported outcome score) EQ5D (validated quality of life score). Complexity was assessed using COFAS pre-operative grade. Results: Implant survivorship was 93.8% at 2 years minimum. Median age was 68 (42-92), male: female 72:41. Mean MOxFQ improved by 28, mean EQ5D by 1.4 and mean VAS by 7. 16 cases had planned additional procedures, 5 required intra-operative medial malleolar fixation. There have been 2 revisions for deep infection, 2 for implant subsidence, 1 for instability and 2 for unexplained pain (6.2%). 5 patients have required further surgery to the ankle and hindfoot with implant retention (4.4%). 3 patients have asymptomatic tibial cysts (3.4%) and 1 patient has an asymptomatic talar cyst (0.9%) - there is no evidence of progression or loosening. Conclusion: We report favourable early functional, radiographic and survivorship outcomes of this implant in the UK population.

BackgroundDeliberate self-harm (DSH) is common in adolescents in the United Kingdom and suicide has greatly increased in frequency in older male adolescents. There is, however, very little information about DSH in older children and young adolescents.MethodAnalysis of data collected by the Oxford Monitoring System for Attempted Suicide between 1976 and 1993 for all cases of DSH in under 16-year-olds referred to the general hospital in Oxford.ResultsSeven hundred and fifty-five individuals were involved in 854 episodes of DSH. There were very few cases under 12 years of age but after that the behaviour increased greatly in frequency with each year of age, especially in girls. Eighty-five per cent were girls, the sex ratio being 5.7 girls to each boy. Most cases involved self-poisoning. During the final six years of the study period paracetamol was involved in 54.7% of overdoses, compared with 19.5% in 1976–1981. A minority of individuals had had previous psychiatric treatment. The most frequent problems were relationship difficulties with parents, followed by difficulties with friends, school and social isolation. Among those who reported previous episodes of DSH, in the majority of cases these had not come to medical attention. Repetition of self-harm occurred in 9.4% of cases within a year of an episode and 19.3% during the overall study period. There was some indication that repetition was most common in youngsters discharged from the Accident and Emergency Department without a psychiatric assessment.ConclusionsDSH in under 16-year-olds is not uncommon and there is evidence that it occurs far more frequently in the community than is reflected in general hospital figures. The problem of paracetamol self-poisoning in this age group needs to be addressed. A psychiatric assessment should be performed in all cases coming to the general hospital.

Objectives — To develop a method of community based growth assessment. Setting — Oxford District, United Kingdom. Methods — A system of growth surveillance involving a community consultant paediatrician, a paediatric endocrinologist, a clinical auxologist, a project coordinator, and the many primary health care teams was started. Letters and meetings were arranged to introduce the programme to general practitioners and health visitors, emphasising the importance of growth assessment in normal child development. They were asked to measure all children as part of their routine developmental checks at 3 and 4·5 years of age. Community growth assessment clinics staffed by an experienced auxologist were established. Children whose heights were more than two standard deviation (SD) scores below the mean or whose height SD score decreased between the two ages were referred to the clinic. Any child whose height was more than 3 SD scores below the mean was referred directly to the paediatric endocrinologist. Those seen in the community clinics were followed up for a year and if their velocity was >25th centile, karyotype normal, and bone age appropriately delayed, they were discharged to the general practitioner for further follow up. Any child with an annual velocity <25th centile was referred to the endocrinologist. Results — Of 20 338 children monitored, 260 (1·3%) had heights >−2 SD scores. Seventy six were lost to follow up, 35 were measuring errors, 69 were already seeing a paediatrician, leaving 80 children to be evaluated. Of these, 69 were “short normals” and 11 were newly identified diagnoses. Conclusions — This system of secondary referral keeps normal healthy children out of hospital, avoids unnecessary over-investigation, reduces travel and anxiety for families, avoids filling specialist clinics with normal children, and provides an inexpensive system of growth surveillance.

Objective Octogenarians, as the fastest growing stratum of the population and with the highest prevalence of coronary artery disease, are being increasingly referred for coronary artery bypass grafting (CABG). The general perception is that the presence of comorbidities and the propensity for neurological injury expose them to a higher risk for mortality and morbidity after conventional on-pump CABG, and therefore, off-pump CABG should be preferentially offered to octogenarians to improve outcomes. This study evaluates the in-hospital outcomes and predictors of mortality and stroke in octogenarians undergoing on- and off-pump CABG at our institution. Methods From January 2000 to December 2010, a total of 290 octogenarians underwent off-pump (n = 217) and on-pump (n = 73) CABG. Their data were prospectively entered into the cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Outcome measures included in-hospital mortality, major complications, and length of stay. Multivariate analysis was performed to identify predictors of combined outcome of in-hospital mortality and stroke. Results The mean ± SD age of the patients was 82 ± 2.0 years. Preoperative demographics were similar for the on-pump and off-pump groups. The patients who underwent off-pump CABG had a lower number of distal anastomoses performed compared with the patients who underwent on-pump CABG [mean difference, 0.2; 95% confidence interval (CI), 0.02–0.4; P = 0.03]. However, the ratio of grafts (received/needed) was the same in both groups. In-hospital mortality for the entire cohort was 7.2%, with no significant difference between the groups for death (6.0% vs 11.0%; P = 0.08), stroke (2.8% vs 2.8%; P = 1.0), other major complications, and length of hospital stay. Independent predictors of combined outcome identified from the multiple logistic model included heart failure [odds ratio (OR), 4.4; 95% CI, 1.5–13.0; P = 0.008], diabetes (OR, 2.6; 95% CI, 1.0–6.0; P = 0.046), nitrate infusion (OR, 2.9; 95% CI, 1.1–8.0; P = 0.04), postoperative renal failure requiring hemofiltration (OR, 8.6; 95% CI, 3.5–21.1; P < 0.001), and postoperative ventricular arrhythmias (OR, 7.3; 95% CI, 1.9–27.8; P = 0.009). Conclusions Both on-pump and off-pump CABG are reasonable revascularization strategies in octogenarians. Careful patient selection and individualized treatment decisions can minimize postoperative mortality and morbidity in octogenarians undergoing on- and off-pump CABG.

Background The selection of mitral valve surgery, including mitral valve repair and mitral valve replacement, is still an important dilemma for patients with chronic ischemic mitral regurgitation. We carry out a meta-analysis to evaluate the effectiveness and safety of mitral valve repair versus replacement for ischemic mitral regurgitation. Methods We searched PubMed, Embase, the Cochrane Library, and Web of Science to identify studies from their inception to July 2015. A meta-analysis was performed using RevMan 5.3 software (Cochrane Collaboration, Oxford, United Kingdom). A random-effect model was used and sensitivity analysis was performed on studies reporting on operation after 2000, high-quality studies, and those studies reporting on more than 150 patients. Result A total of 2,324 patients were identified from 10 retrospective studies. Mitral valve repair was associated with a trend toward lower operative mortality (odds ratio [OR] = 0.45; 95% confidence interval [CI]: 0.31–0.65; p < 0.0001) and higher recurrence of mitral regurgitation (OR = 5.89; 95% CI: 3.34–10.39; p < 0.00001). Five-year survival rate was similar between the two groups (OR = 1.20; 95% CI: 0.88–1.65; p = 0.25). No differences in reoperation, the incidence of acute renal failure and acute respiratory failure, the length of ICU stay, and the length of hospital stay were found. Conclusion Mitral valve repair was associated with lower operative mortality but a higher recurrence of mitral regurgitation compared with mitral valve replacement. Owing to the limited quantity and quality of the included studies, this conclusion still needs to be further confirmed by conducting more high-quality, multicenter randomized controlled trials with large sample size.

Abstract Background Motor neuron diseases cause progressive degeneration of upper and lower motor neurons. No Indian studies are available on diffusion tensor imaging (DTI) findings in these patients. Aims This study was done to identify white matter tracts that have reduced fractional anisotropy (FA) in motor neuron disease (MND) patients using tract-based spatial statistics and to correlate FA values with Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) score. Settings and Design A case–control study in a tertiary care hospital. Materials and Methods We did DTI sequence (20 gradient directions, b-value 1,000) in 15 MND patients (10 men and 5 women; mean age: 46.5 ± 16.5 years; 11 amyotrophic lateral sclerosis [ALS], 2 monomelic amyotrophy, 1 progressive muscular atrophy, and 1 bulbar ALS) and 15 age- and sex-matched controls. The data set from each subject was postprocessed using FSL downloaded from the FMRIB Software Library, Oxford, United Kingdom (http://www.fmrib.ox.ac.uk/fsl). Statistical Analysis The statistical permutation tool “randomize” with 5,000 permutations was used to identify voxels that were different between the patient data set and the control data set. Mean FA values of these voxels were obtained separately for each tract as per “JHU white-matter tractography atlas.” SPSS was used to look to correlate tract-wise mean FA value with ALSFRS-R score. Results We found clusters of reduced FA values in multiple tracts in the brain of patients with MND. Receiver operating characteristic curves plotted for individual tracts, showed that bilateral corticospinal tract, bilateral anterior thalamic radiation, bilateral uncinate fasciculus, and right superior longitudinal fasciculus were the best discriminators (area under the curve > 0.8, p < 0.01). FA values did not correlate with ALFRS-R severity score. Conclusion In MND patients, not only the motor tracts, but several nonmotor association tracts are additionally affected, reflecting nonmotor pathological processes in ALS.

Background Routinely recorded primary care data have been used for many years by sentinel networks for surveillance. More recently, real world data have been used for a wider range of research projects to support rapid, inexpensive clinical trials. Because the partial national lockdown in the United Kingdom due to the coronavirus disease (COVID-19) pandemic has resulted in decreasing community disease incidence, much larger numbers of general practices are needed to deliver effective COVID-19 surveillance and contribute to in-pandemic clinical trials. Objective The aim of this protocol is to describe the rapid design and development of the Oxford Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) and its first two platforms. The Surveillance Platform will provide extended primary care surveillance, while the Trials Platform is a streamlined clinical trials platform that will be integrated into routine primary care practice. Methods We will apply the FAIR (Findable, Accessible, Interoperable, and Reusable) metadata principles to a new, integrated digital health hub that will extract routinely collected general practice electronic health data for use in clinical trials and provide enhanced communicable disease surveillance. The hub will be findable through membership in Health Data Research UK and European metadata repositories. Accessibility through an online application system will provide access to study-ready data sets or developed custom data sets. Interoperability will be facilitated by fixed linkage to other key sources such as Hospital Episodes Statistics and the Office of National Statistics using pseudonymized data. All semantic descriptors (ie, ontologies) and code used for analysis will be made available to accelerate analyses. We will also make data available using common data models, starting with the US Food and Drug Administration Sentinel and Observational Medical Outcomes Partnership approaches, to facilitate international studies. The Surveillance Platform will provide access to data for health protection and promotion work as authorized through agreements between Oxford, the Royal College of General Practitioners, and Public Health England. All studies using the Trials Platform will go through appropriate ethical and other regulatory approval processes. Results The hub will be a bottom-up, professionally led network that will provide benefits for member practices, our health service, and the population served. Data will only be used for SQUIRE (surveillance, quality improvement, research, and education) purposes. We have already received positive responses from practices, and the number of practices in the network has doubled to over 1150 since February 2020. COVID-19 surveillance has resulted in tripling of the number of virology sites to 293 (target 300), which has aided the collection of the largest ever weekly total of surveillance swabs in the United Kingdom as well as over 3000 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serology samples. Practices are recruiting to the PRINCIPLE (Platform Randomised trial of INterventions against COVID-19 In older PeopLE) trial, and these participants will be followed up through ORCHID. These initial outputs demonstrate the feasibility of ORCHID to provide an extended national digital health hub. Conclusions ORCHID will provide equitable and innovative use of big data through a professionally led national primary care network and the application of FAIR principles. The secure data hub will host routinely collected general practice data linked to other key health care repositories for clinical trials and support enhanced in situ surveillance without always requiring large volume data extracts. ORCHID will support rapid data extraction, analysis, and dissemination with the aim of improving future research and development in general practice to positively impact patient care. International Registered Report Identifier (IRRID) DERR1-10.2196/19773

Background: Knee osteoarthritis (OA) affects an estimated 1 in 5 individuals older than 45 years of age in the United Kingdom. Previous studies have suggested that germanium-infused garments may provide improved clinical outcomes in OA. Germanium-embedded (GE) knee sleeves embrace this fabric technology. Purpose: To assess the outcomes of GE knee sleeves for patients with knee OA. Study Design: Cohort study; Level of evidence, 2. Methods: This study was undertaken at a hospital in the United Kingdom. Patients who had radiographic features of OA, experienced knee pain for at least 6 months, and opted for nonsurgical intervention were included. Patients were recruited over 3 months. The University of California, Los Angeles activity score, Lysholm score, visual analog scale (VAS) score, and Oxford Knee Score (OKS) were collected at monthly intervals for 6 months. Patients were followed to determine their compliance with wearing the knee sleeves at all times, as advised, and whether any adverse effects had occurred. Results: A total of 50 participants were recruited for the study; 4 participants were excluded due to pain and were converted to surgical management. Therefore, 46 patients were analyzed and placed into 2 groups according to severity of OA, as classified by the Kellgren-Lawrence system: group A had grade 1 or 2 OA, and group B had grade 3 or 4 OA. There were 25 patients in group A and 21 in group B. Improvements were seen in OKS, VAS, and Lysholm scores in both groups. Clinically significant improvements were seen in group A only for OKS (mean increase, 14), VAS (mean decrease, 4.1), and Lysholm (mean increase, 17.2) scores. These results were also statistically significant (OKS, P = 5.8 × 10-7; VAS, P = 7.7 × 10-12; Lysholm, P = 4.2 × 10-11). The data from this study demonstrated that GE knee sleeves gave better outcomes for patients with grades 1 and 2 OA compared with patients with more advanced disease, which is consistent with previous studies. A total of 3 patients reported skin irritation, which resolved with simple skin ointment application. No patients reported infection, deep vein thrombosis, or circulation problems. Conclusion: GE knee sleeves could play an important role in optimizing nonsurgical management of patients with knee OA, especially patients with grades 1 and 2 OA, as demonstrated by the clinically significant improvements.

Introduction The demand for spinal fusion surgery has increased over the last decades. Health care providers should take costs and cost-effectiveness of these surgeries into account. Open transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are two widely used techniques for spinal fusion. Earlier research revealed that TLIF is associated with less blood loss, shorter surgical time and sometimes shorter length of hospital stay, while effectiveness of both techniques on back and/or leg pain are equal. Therefore, TLIF could result in lower costs and be more cost-effective than PLIF. This is the first systematic review comparing direct and indirect (partial) economic evaluations of TLIF with PLIF in adults with lumbar spondylolisthesis. Furthermore, methodological quality of included studies was assessed. Methods Searches were conducted in eight databases for reporting on eligibility criteria; TLIF or PLIF, lumbar spondylolisthesis or lumbar instability, and cost. Costs were converted to United States Dollars with reference year 2020. Study quality was assessed using the bias assessment tool of the Cochrane Handbook for Systematic Reviews of Interventions, the Level of Evidence guidelines of the Oxford Centre for Evidence-based Medicine and the Consensus Health Economic Criteria (CHEC) list. Results Of a total of 693 studies, 16 studies were included. Comparison of TLIF and PLIF could only be made indirectly, since no study compared TLIF and PLIF directly. There was a large heterogeneity in health care and societal perspective costs due to different in-, and exclusion criteria, baseline characteristics and the use of costs or charges in calculations. Health care perspective costs, calculated with hospital costs, ranged from $15,867-$43,217 in TLIF-studies and $32,662 in one PLIF-study. Calculated with hospital charges, it ranged from $8,964-$51,469 in TLIF-studies and $21,838-$93,609 in two PLIF-studies. Societal perspective costs and cost-effectiveness, only mentioned in TLIF-studies, ranged from $5,702/QALY-$48,538/QALY and $50,092/QALY-$90,977/QALY, respectively. Overall quality of studies was low. Conclusions This systematic review shows that TLIF and PLIF are expensive techniques. Moreover, firm conclusions about the preferable technique, based on (partial) economic evaluations, cannot be drawn due to limited studies and heterogeneity. Randomized prospective trials and full economical evaluations with direct TLIF and PLIF comparison are needed to obtain high levels of evidence. Furthermore, development of guidelines to perform adequate economic evaluations, specified for the field of interest, will be useful to minimize heterogeneity and maximize transferability of results. Trial registration Prospero-database registration number: CRD42020196869.

Resumen Antecedentes La incontinencia urinaria es un síndrome geriátrico muy frecuente, afecta la calidad de vida y es un factor contribuyente para el deterioro funcional. Su prevalencia en general es alta y más en los institucionalizados. El manejo conservador con intervenciones sobre el estilo de vida, modificaciones de la conducta y rehabilitación del suelo pélvico ha demostrado ser efectivo como terapia para todos los tipos de incontinencia urinaria. Objetivo Evaluar los resultados del programa de terapia integral de incontinencia urinaria en personas adultos mayores, en la Unidad de Incontinencia Urinaria del Hospital Nacional de Geriatría y Gerontología. Métodos Se realizó un estudio de tipo observacional descriptivo de corte transversal, basado en revisión de expedientes y fichas de enfermería de los adultos mayores que asistieron a la Unidad de Incontinencia Urinaria del Hospital Nacional de Geriatría y Gerontología entre enero y diciembre del 2015. Se analizó en base los resultados de las variables: nictámero, severidad de la incontinencia urinaria (frecuencia x cantidad), fuerza muscular del suelo pélvico (escala de Oxford), evaluación de la calidad de vida y mejoría subjetiva, al inicio y al final del tratamiento. Se compararon porcentajes de pacientes que lograron mejoría en cada una de las variables. Resultados Se estudiaron 129 adultos mayores, con una edad en promedio de 76,3 años de los cuales 96% eran mujeres. La forma de presentación más frecuente fue la incontinencia urinaria mixta, seguido de la incontinencia urinaria de esfuerzo y por último la incontinencia urinaria de urgencia. El 59% (p < 0,001) lograron un hábito miccional normal según nictámero, el 21% (p 0,001) lograron ser continentes, el 19% aumentaron la fuerza muscular del suelo pélvico (0,95 puntos en una escala de 0 a 5). El 58,2% de los adultos mayores manifestaron una buena o excelente mejoría subjetiva en sus síntomas (p < 0,001). La calidad de vida demostró mejoría, se obtuvo en promedio una disminución de la afectación de 5 puntos (escala ICI-Q de 0 a 10 puntos), (p < 0,05). Conclusiones La terapia integral con abordaje conservador en adulto mayor con incontinencia urinaria demostró buenos resultados, por lo tanto, debe ser recomendado como primera opción antes de un tratamiento quirúrgico. Ya que los ejercicios musculares pueden ser aprendidos con instrucción, la electroestimulación es de fácil aplicación y escasos riesgos de efectos secundarios.

Abstract Background Our objective was to describe the clinical course, risk factors and outcomes of patients infected with COVID-19 around the globe comparing cancer to non-cancer patients. Methods We conducted a retrospective cohort study of COVID-19 confirmed cases through an international multicenter collaboration including 17 centers around the world including the United States of America, Brazil, Europe, Far East, Middle East and Australia from January to date. We evaluated the patients’ clinical characteristics, clinical course of the disease, hospitalization and outcome. Death was considered to be COVID-associated if it occurred within 30 days from the time of diagnosis. Results Preliminary data on 571 patients included 186 cancer patients and 385 non-cancer patients. Cancer patients were more likely to have COPD and received steroids but were less likely to have COVID-related symptoms compared to non-cancer patients (84% vs 97%, p&lt; 0.0001). The rate of pneumonia with hypoxia, non-invasive ventilation and mechanical ventilation were similar in both groups. Despite the fact that hospital admissions were significantly higher in non-cancer patients (70% vs 56%, p&lt; 0.001), promising antiviral and immune-related therapy including remdesivir, convalescent plasma and immunomodulators were more commonly used in cancer patients compared to non-cancer patients (P=0.04). Cancer patients had a higher COVID-associated mortality rate compared to non-cancer patients (20% vs 11%, p=0.006). Conclusion Despite the fact that cancer patients received more frequent antiviral and immune-related therapy, the mortality rate among cancer patients was significantly higher than non-cancer patients. Disclosures Roy F. Chemaly, MD, MPH, FACP, FIDSA, Chimerix (Consultant, Research Grant or Support)Clinigen (Consultant)Merck (Consultant, Research Grant or Support)Novartis (Research Grant or Support)Oxford Immunotec (Consultant, Research Grant or Support)Shire/Takeda (Research Grant or Support)Viracor (Research Grant or Support) Issam I. Raad, MD, Citius (Other Financial or Material Support, Ownership interest)Cook Medical (Grant/Research Support)Inventive Protocol (Other Financial or Material Support, Ownership interest)Novel Anti-Infective Technologies (Shareholder, Other Financial or Material Support, Ownership interest)

Abstract Background Conventional culture tests usually identify only a few bacterial species, which can grow well in the culture system, in the cases of polybacterial infection. 16S rRNA gene nanopore sequencing enables semi-quantitative identification of bacterial genetic materials. We aimed to evaluate usefulness of 16s rRNA gene nanopore sequencing in the cases suspected of polybacterial infection. Methods The research was conducted in a single university hospital for one year. Conventional bacterial culture identification and nanopore sequencing of 16s rRNA gene were carried out simultaneously for cases where polybacterial infection is strongly suspected. Blood agar plate was used for conventional culture, and Microscan (Beckman Coulter, United States) and Vitek 2 (Biomerieux, FR) automated systems were used for identification. For nanopore sequencing, 16S rRNA gene PCR was performed from the clinical specimens, and sequencing libraries were generated from the PCR products using the rapid barcoding sequencing kit (Oxford nanopore technologies, UK). MinION sequencing was performed for 1–3 hours and the generated reads were analyzed using the EPI2ME 16S BLAST workflow. Results Specimens were obtained from 15 patients; 6 liver abscess, 2 psoas abscess, 2 thigh abcess, 1 paraspinal abscess, 1 mycotic aneurysm, 1 necrotizing fasciitis, 1 fingertip gangrene and 1 abscess in coccyx area. 16s rRNA gene nanopore sequencing showed monobacterial organism in 8 (53.3%) specimens and polybacterial organisms in 7 (46.6%) specimens. In three (37.5%) cases of 8 cases with monobacterial infections identified by 16s rRNA gene sequencing, no organism was grown in conventional culture, possibly due to previous antibiotic administration. Notably, among 8 cases with polybacterial infection by 16s rRNA gene nanopore sequencing test, traditional culture test showed polybacterial infection in only two (25%) cases and single bacterial organism was identified in the other 6 (75%) cases. Conclusion Nanopore sequencing of 16s rRNA gene using the MinION sequencer may be useful for identification of causing microorganism and differentiation between monobacterial and polybacterial infection when polybacterial infection is suspected. Disclosures All authors: No reported disclosures.

AbstractIntroductionEarthquake-related trauma results in crush injuries and bony- and soft-tissue trauma. There are no systematic reviews analyzing the typical injury patterns and treatments in “Mega-Mass-Casualty” earthquakes. The characterization of an injury pattern specific to disaster type, be it natural or manmade, is imperative to build an effective disaster preparedness and response system.MethodsThe systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy was developed to identify all publications relating to earthquakes and the orthopedic treatment in adult patients. The following databases were searched: PubMed (Medline; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), Ovid (Ovid Technologies; New York, New York USA), Web of Science (Thomson Reuters; New York, New York USA), and The Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom).ResultsThe searches identified 4,704 articles: 4,445 after duplicates were removed. The papers were screened for title and abstract and 65 out of those were selected for full-text analysis. The quality of data does not permit a standard-of-care (SOC) to be defined. Scarcity and poor quality of the data collected also may suggest a low level of accountability of the activity of the international hospital teams. Qualitatively, it is possible to define that there are more open fractures during daytime hours than at night. Excluding data about open and closed fractures, for all types of injuries, the results underline that the higher the impact of the earthquake, as measured by Richter Magnitude Scale (RMS), the higher is the number of injuries.DiscussionRegarding orthopedic injuries during earthquakes, special attention must be paid to the management of the lower limbs most frequently injured. Spinal cord involvement following spine fractures is an important issue: this underlines how a neurosurgeon on a disaster team could be an important asset during the response. Conservative treatment for fractures, when possible, should be encouraged in a disaster setting. Regarding amputation, it is important to underline how the response and the quality of health care delivered is different from one team to another. This study shows how important it is to improve, and to require, the accountability of international disaster teams in terms of type and quality of health care delivered, and to standardize the data collection.BortolinM, MorelliI, VoskanyanA, JoyceNR, CiottoneGR. Earthquake-related orthopedic injuries in adult population: a systematic review. Prehosp Disaster Med. 2017;32(2):201–208.

Background One in 10 people in the United Kingdom will need a total knee replacement (TKR) during their lifetime. Access to this life-changing operation has recently been restricted based on body mass index (BMI) due to belief that high BMI may lead to poorer outcomes. We investigated the associations between BMI and revision surgery, mortality, and pain/function using what we believe to be the world’s largest joint replacement registry. Methods and findings We analysed 493,710 TKRs in the National Joint Registry (NJR) for England, Wales, Northern Ireland, and the Isle of Man from 2005 to 2016 to investigate 90-day mortality and 10-year cumulative revision. Hospital Episodes Statistics (HES) and Patient Reported Outcome Measures (PROMs) databases were linked to the NJR to investigate change in Oxford Knee Score (OKS) 6 months postoperatively. After adjustment for age, sex, American Society of Anaesthesiologists (ASA) grade, indication for operation, year of primary TKR, and fixation type, patients with high BMI were more likely to undergo revision surgery within 10 years compared to those with “normal” BMI (obese class II hazard ratio (HR) 1.21, 95% CI: 1.10, 1.32 (p < 0.001) and obese class III HR 1.13, 95% CI: 1.02, 1.26 (p = 0.026)). All BMI classes had revision estimates within the recognised 10-year benchmark of 5%. Overweight and obese class I patients had lower mortality than patients with “normal” BMI (HR 0.76, 95% CI: 0.65, 0.90 (p = 0.001) and HR 0.69, 95% CI: 0.58, 0.82 (p < 0.001)). All BMI categories saw absolute increases in OKS after 6 months (range 18–20 points). The relative improvement in OKS was lower in overweight and obese patients than those with “normal” BMI, but the difference was below the minimal detectable change (MDC; 4 points). The main limitations were missing BMI particularly in the early years of data collection and a potential selection bias effect of surgeons selecting the fitter patients with raised BMI for surgery. Conclusions Given revision estimates in all BMI groups below the recognised threshold, no evidence of increased mortality, and difference in change in OKS below the MDC, this large national registry shows no evidence of poorer outcomes in patients with high BMI. This study does not support rationing of TKR based on increased BMI.

AbstractIntroductionHistorically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC.ProblemQuality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature.MethodsA scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment.ResultsThe majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review.ConclusionOverall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized.HowardI, CameronP, WallisL, CastrenM, LindstromV. Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43–52.

Background:EULAR has recommended ultrasonography (US) as first imaging modality for diagnosis of Giant Cell Arteritis (GCA)1. For patients with a high pre-test probability who have a negative scan, the recommendation is to use another diagnostic modality like temporal artery biopsy (TAB) to make a diagnosis1. We know that a fast-track pathway incorporating US, results in better clinical outcomes2; but there are little data on the health-economics of this approach. Since 2017, we have used ultrasonography as the primary diagnostic modality for suspected GCA. In patients with a high pre-test probability with a negative ultrasonography, we perform a temporal artery biopsy.Objectives:To compare the cost of investigating GCA using first-line US and second-line TAB the use of TAB only. To compare the cost per definite diagnosis of GCA.Methods:Number of cases from 2007-2009 and 2017-2019 were calculated by the number of TAB performed and number of referrals to hospital GCA clinic, respectively. Costs of the procedure were calculated as per the nationally agreed tariff by the United Kingdom National Health Service. For ease of comparison, we used the 2018/19 tariff (£1284/TAB; £51 for US)Results:In 2007-2009, 162 cases were referred to clinic and had a TAB, of which 86 were positive. No cases had US. The 2018/19 corrected cost was £208008; the cost per positive diagnosis was £2418.70 (Table 1).In 2017-2019, 419 patients were referred to the GCA clinic, 416 of whom had US for diagnosis. 3 individuals had a TAB as the first diagnostic modality and 66 others were referred for a TAB because of a high pre-test probability and negative US. The 2018/19 corrected cost of this pathway was £109812 and the cost per positive diagnosis was £773.32 (Table 1).Table 1.Numbers of cases investigated for suspected GCA by TAB or US and the costs corrected to 2018/19 UK NHS tariff.YearsNo of referralsNo of TABNo of USNo of patients with GCATotal costCost of making 1 positive diagnosis2007-09162162086£208008£2418.702017-1941969416142£109812£773.32If all cases in 2017-2019 had a TAB for suspected GCA, the 2018/19 corrected cost would have been £537996. The estimated 2018/19 corrected savings in our center was £142728/year. The estimated 2018/19 corrected savings per definite diagnosis of GCA has dropped by £1645.37 (Table 1).Conclusion:The EULAR recommendation of using first-line US for diagnosis of GCA followed by a TAB in cases with uncertain diagnosis after US, is highly cost-effective in the UK, resulting in cost savings of >£140K per year.References:[1]Dejaco C, et al. Ann Rheum Dis. 2018 May;77(5):636-643.[2]Diamantopoulos AP, et al. Rheumatology (Oxford). 2016 Jan;55(1):66-70.Disclosure of Interests:None declared

Background:In the absence of evidence-based treatment guidelines, medication use in SLE is highly variable. Low rates of remission and lupus low disease activity state (LLDAS) suggest that suboptimal responses to standard medications, which include glucocorticoids (GC), anti-malarial (AM) drugs and immunosuppressive (IS) agents, are common. Understanding the utility of current medications will facilitate the selection of patients for advanced therapies as they emerge.Objectives:To examine medication use patterns in a large multicentre SLE cohort.Methods:We used 2013-18 data from the Asia Pacific Lupus Collaboration (APLC) cohort in which disease activity (SLEDAI-2K) and medication details were captured at every visit. LLDAS was defined as in Golderet al., 2019 (1). We examined the use of medication (med) categories (GC &/or AM &/or IS) by SLE disease activity and LLDAS at the visit level. Additionally, we performed Cox regression analyses to determine the time-to-discontinuation of meds stratified by SLE disease activity, ranked by time-adjusted mean SLEDAI-2K, and by percent-time spent in LLDAS.Results:We analysed data from 19,804 visits of 2,860 patients. We observed 8 med categories: no meds; GC, AM or IS only; GC+AM; GC+IS; AM+IS and GC+AM+IS (triple therapy). Triple therapy was the most frequent med pattern (32%); single agents were used in 21% of visits and biologicals in only 3%. Among visits where SLEDAI-2K was ≥10, triple therapy was used in 46%, with median [IQR] GC dose 10 [6, 24] mg/day; in contrast, among visits with SLEDAI-2K≤4 triple therapy was used in 28% (p<0.01). Patients in LLDAS received less combination therapy than those who were not in LLDAS.Med persistence (survival analysis) varied widely, with lowest survivals for IS. Patients with time-adjusted mean SLEDAI-2K ≥10 had lower discontinuation of GC and higher discontinuation of IS including azathioprine, leflunomide and cyclosporine (Table 1). In contrast, increased time in LLDAS was associated with reduced discontinuation of AM and azathioprine.GCAMISMPhMPhAAZAMTXCyALEFOverall med survival, days to 25% discontinuation (95%CI)1048(938, 1197)1267(1113, 1428)175(175, 182)387(252, 756)409(350, 476)525(219, 686)268(182, 350)329(190, 524)Univariable associations,HR (95% CI) p-valueDisease activity≤41.001.001.001.001.001.001.001.00>4 & <100.69 (0.56,0.84)p<0.0011.15 (0.92,1.44)0.20.92 (0.80,1.05)0.21.37 (0.78,2.42)0.31.16 (0.97,1.39)0.111.11 (0.72,1.71)0.61.26 (0.90,1.77) 0.181.88 (1.07,3.30) 0.03≥100.65 (0.35,1.21) 0.181.56 (0.94,2.59) 0.080.84 (0.45,1.57)0.61.92 (0.80,4.63)0.142.69 (1.86,3.91) p<0.0011.85 (0.92,3.71) 0.082.66 (1.36,5.21) 0.0041.62 (1.13,2.32)0.009LLDAS<50%1.001.001.001.001.001.001.001.00≥50%1.30 (1.09, 1.55)0.0030.67 (0.54, 0.84)<0.0011.22 (1.08, 1.40)0.0020.83 (0.44,1.57)0.60.83 (0.69, 1.00)0.0540.70 (0.46, 1.07)0.101.29 (0.92, 1.83)0.140.43 (1.5, 1.25)0.12Conclusion:In a large multicentre SLE cohort, most patients were receiving combination treatment. AM treatment survival was high and associated with low disease activity, GC survival was high and associated with high disease activity, while IS survival was low. Patients with high disease activity received more medication combinations but had reduced IS survival. These data suggest ongoing unmet need for improved medications for treatment of SLE.Reference:Golder, V., et al Lancet Rheum. 2019 1(2):e95-102Disclosure of Interests:Rangi Kandane-Rathnayake Grant/research support from: The APLC has received financial (non-restricted educational) grants from AstraZeneca, Bristol Myers Squibb, GlaxoSmithKline, Janssen, EMD Serono, Eli Lilly and UCB for the LLDAS Validation Study., Worawit Louthrenoo: None declared, Shue Fen Luo: None declared, Yeong-Jian Wu Consultant of: Pfizer, Lilly, Novartis, Abbvie, Roche, Speakers bureau: Lilly, Novartis, Yi-Hsing Chen Grant/research support from: Taiwan Ministry of Science and Technology, Taiwan Department of Health, Taichung Veterans General Hospital, National Yang-Ming University, GSK, Pfizer, BMS., Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead., Paid instructor for: Pfizer, Novartis, Johnson & Johnson, Roche, Lilly, Astra& Zeneca, Sanofi, Astellas, Agnitio Science Technology, United Biopharma., Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead., Vera Golder: None declared, Aisha Lateef: None declared, Jiacai Cho: None declared, Sandra Navarra Speakers bureau: Astellas, Novartis, Pfizer, Johnson & Johnson, Abbvie, Leonid Zamora: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Tanabe, Abbot, Dexa Medica, Roche, Sargunan Sockalingam: None declared, Yuan An: None declared, Zhanguo Li: None declared, Yasuhiro Katsumata: None declared, masayoshi harigai Grant/research support from: AbbVie Japan GK, Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., and Teijin Pharma Ltd. MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Oxford Immuotec, Pfizer Japan Inc., and Teijin Pharma Ltd. MH is a consultant for AbbVie, Boehringer-ingelheim, Kissei Pharmaceutical Co., Ltd. and Teijin Pharma., Yanjie Hao: None declared, Zhuoli Zhang: None declared, Madelynn Chan: None declared, Jun Kikuchi: None declared, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd., Fiona Goldblatt: None declared, Sean O’Neill: None declared, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Jennifer H. Lofland Employee of: Janssen, Sang-Cheol Bae: None declared, Chak Sing Lau: None declared, Alberta Hoi: None declared, Mandana Nikpour: None declared, Eric F. Morand Grant/research support from: AstraZeneca, Consultant of: AstraZeneca, Speakers bureau: AstraZeneca

Abstract Background Hypertension is a major cause of morbidity and mortality. In community populations the prevalence of hypertension, both in diagnosed and undiagnosed states, has been widely reported. However, estimates for the prevalence of hospitalized patients with average blood pressures (BPs) that meet criteria for the diagnosis of hypertension are lacking. We aimed to estimate the prevalence of patients in a UK hospital setting, whose average BPs meet current international guidelines for hypertension diagnosis. Methods We performed a retrospective cross-sectional observational study of patients admitted to adult wards in 4 acute hospitals in Oxford, United Kingdom, between March 2014 and April 2018. Results We identified 41,455 eligible admitted patients with a total of 1.7 million BP measurements recorded during their hospital admissions. According to European ESC/ESH diagnostic criteria for hypertension, 21.4% (respectively 47% according to American ACC/AHA diagnostic criteria) of patients had a mean BP exceeding the diagnostic threshold for either Stage 1, 2, or 3 hypertension. Similarly, 5% had a mean BP exceeding the ESC/ESH (respectively 13% had a mean BP exceeding the ACC/AHA) diagnostic criteria for hypertension, but no preexisting diagnostic code for hypertension or a prescribed antihypertensive medication during their hospital stay. Conclusions Large numbers of hospital inpatients have mean in-hospital BPs exceeding diagnostic thresholds for hypertension, with no evidence of diagnosis or treatment in the electronic record. Whether opportunistic screening for in-hospital high BP is a useful way of detecting people with undiagnosed hypertension needs evaluation.

Abstract Background Corona Virus Disease 19 (COVID-19) is a new pandemic, declared a public health emergency by the World Health Organization, which could have negative consequences for pregnant and postpartum women. The scarce evidence published to date suggests that perinatal mental health has deteriorated since the COVID-19 outbreak. However, the few studies published so far have some limitations, such as a cross-sectional design and the omission of important factors for the understanding of perinatal mental health, including governmental restriction measures and healthcare practices implemented at the maternity hospitals. Within the Riseup-PPD COST Action, a study is underway to assess the impact of COVID-19 in perinatal mental health. The primary objectives are to (1) evaluate changes in perinatal mental health outcomes; and (2) determine the risk and protective factors for perinatal mental health during the COVID-19 pandemic. Additionally, we will compare the results between the countries participating in the study. Methods This is an international prospective cohort study, with a baseline and three follow-up assessments over a six-month period. It is being carried out in 11 European countries (Albania, Bulgaria, Cyprus, France, Greece, Israel, Malta, Portugal, Spain, Turkey, and the United Kingdom), Argentina, Brazil and Chile. The sample consists of adult pregnant and postpartum women (with infants up to 6 months of age). The assessment includes measures on COVID-19 epidemiology and public health measures (Oxford COVID-19 Government Response Tracker dataset), Coronavirus Perinatal Experiences (COPE questionnaires), psychological distress (BSI-18), depression (EPDS), anxiety (GAD-7) and post-traumatic stress symptoms (PTSD checklist for DSM-V). Discussion This study will provide important information for understanding the impact of the COVID-19 pandemic on perinatal mental health and well-being, including the identification of potential risk and protective factors by implementing predictive models using machine learning techniques. The findings will help policymakers develop suitable guidelines and prevention strategies for perinatal mental health and contribute to designing tailored mental health interventions. Trial registration ClinicalTrials.gov Identifier: NCT04595123.

Investigations suggest that the latest case of inhalation anthrax in the United States may have arisen from an envelope that was cross contaminated by contact with other letters containing Bacillus anthracis. This case arose in a 94 year old resident of Oxford, Connecticut. She became unwell on 13 November with fever, cough, weakness, and muscle aches. She was admitted to hospital on 16 November but deteriorated despite treatment and died on 21 November.

Head, Neck and Dental Emergencies is a welcome addition to the popular pocket reference Oxford paperback series. The Second Edition is a revised and upgraded version of the original which was published in 2005. As is evident from the title, the genre revolves explicitly around trauma and other critical conditions involving the major organs residing above the collar bone. The book imparts an in-depth view into the medical and dental aspects of emergencies encountered primarily in the Oral and Maxillofacial setting. The editor, Dr. Mike Perry, is a consultant Maxillofacial Surgeon and Trauma team leader at the University Hospital of North Staffordshire, United Kingdom, who, along with a handful of noteworthy contributors, aptly bestow extensive expertise throughout the course of the book.

Background Influenza virus presents a considerable challenge to public health by causing seasonal epidemics and occasional pandemics. Nanopore metagenomic sequencing has the potential to be deployed for near-patient testing, providing rapid infection diagnosis, rationalising antimicrobial therapy, and supporting infection-control interventions. Aim To evaluate the applicability of this sequencing approach as a routine laboratory test for influenza in clinical settings. Methods We conducted Oxford Nanopore Technologies (Oxford, United Kingdom (UK)) metagenomic sequencing for 180 respiratory samples from a UK hospital during the 2018/19 influenza season, and compared results to routine molecular diagnostic standards (Xpert Xpress Flu/RSV assay; BioFire FilmArray Respiratory Panel 2 assay). We investigated drug resistance, genetic diversity, and nosocomial transmission using influenza sequence data. Results Compared to standard testing, Nanopore metagenomic sequencing was 83% (75/90) sensitive and 93% (84/90) specific for detecting influenza A viruses. Of 59 samples with haemagglutinin subtype determined, 40 were H1 and 19 H3. We identified an influenza A(H3N2) genome encoding the oseltamivir resistance S331R mutation in neuraminidase, potentially associated with an emerging distinct intra-subtype reassortant. Whole genome phylogeny refuted suspicions of a transmission cluster in a ward, but identified two other clusters that likely reflected nosocomial transmission, associated with a predominant community-circulating strain. We also detected other potentially pathogenic viruses and bacteria from the metagenome. Conclusion Nanopore metagenomic sequencing can detect the emergence of novel variants and drug resistance, providing timely insights into antimicrobial stewardship and vaccine design. Full genome generation can help investigate and manage nosocomial outbreaks.

Daniel Brandhorst,1,2 Heide Brandhorst,1,2 Samuel Acreman,1,2 Yukari Kimura,1,2 Shannon Layland,3 Katja Schenke-Layland,3 Paul R.V. Johnson1,2 1 Research Group for Islet Transplantation, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom 2 Oxford Consortium for Islet Transplantation, Oxford Centre for Diabetes, Endocrinology, and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, United Kingdom 3 Natural and Medical Sciences Institute, Eberhard Karls University, Tübingen, Germany Aim Islet isolation essentially requires dissociation of the islet basement membrane by collagenolytic enzymes. Basement membrane loss is associated with reduced islet function and viability. Previous studies demonstrated that individual extracellular matrix proteins (ECMPs) can increase islet survival pre- and post-transplant. In the present study, we tested our hypothesis, that the combination of different ECMPs, particularly those forming suprastructures, are more efficient than individual ECMPs to protect human islets from hypoxia-induced damage. In contrast to previous studies, we dissolved ECMPs in the media rather than to coat culture surfaces. Methods Islets, isolated from pancreases of 11 human DBD donors (50±2 years, 29.3±1.2 BMI, 5.7±0.3 hours CIT), were cultured for 3–4 days in 2% oxygen and suspended in CMRL 1066 (2% FCS) supplemented with either 40 µg/mL of dissolved collagen-IV, 10 µg/mL laminin-521 or 12.5 µg/mL nidogen-1 used individually or as combination. Sham-treated islets (STIs) cultured without ECMPs served as controls. Post-culture characterisation included IEQ yield or islet number (IN), viability (FDA-PI), early plus late apoptosis (annexin V-PI), glucose stimulation index (SI: 2 vs 20 mM) and reactive oxygen species production. Parameters were normalised to IEQ, related to pre-culture data if appropriate and presented as mean ± SEM. Statistical analysis was performed by Friedman test followed by Dunn’s multiple comparison. Results Compared with STI (41±7%), post-culture recovery was higher when hypoxic islets were treated with collagen-IV (64±7%, p<0.001), laminin-521 (57±6%, p<0.01) or nidogen-1 (65±6%, p<0.001) used individually or combined (61±7% p<0.001). This correlated with islet fragmentation (IN/IEQ ratio) that was lower when collagen-IV (116±13%, p<0.001), laminin-521 (114±12%, p<0.01), nidogen-1 (121±12%, p<0.01) or combined ECMPs (119±13%, p<0.001) were compared with STIs (155±16%). Reactive oxygen species production in STIs was substantially reduced by 71±6% (NS), 73±6% (p<0.05), 90±2% (p<0.001), and 87±4% (p<0.001) in presence of collagen-IV, laminin-521, nidogen-1 or combined ECMPs, respectively. This resulted in improved viability (83±7% [p<0.01], 79±9% [p<0.01], 84±7% [p<0.001], 83±8% [p<0.001]) compared with STIs (63±7%). While individual ECMPs stabilised or reduced pre-culture apoptosis (94±17% [p<0.05], 117±16% [p<0.05], 68±13% [p<0.001]), combined ECMPs (171±18%, NS) were equal to STIs (196±28%). STIs did not adequately secrete insulin after glucose challenge (SI 0.97±0.13) in contrast to the physiological insulin response after treatment with collagen-IV (1.76±1.18 [p<0.01]), laminin-521 (1.53±0.25 [NS]), nidogen-1 (2.27±0.67 [p<0.01]) or combined ECMPs (1.95±0.25 [p<0.05]). Conclusion Among the three individual ECMPs tested, nidogen-1 appears to be most effective to protect human islets from hypoxia-induced damage. As its protective efficiency partially exceeds that of combined ECMPs, we have to reject our hypothesis. Further studies are required to clarify whether collagen-IV, laminin-521 and nidogen-1 spontaneously assemble to suprastructures in vitro.

Daniel Brandhorst,1,2 Limor Baruch,3 Heide Brandhorst,1,2 Stasia Krishtul,3 Marcelle Machluf,3 Paul R.V. Johnson1,2 1Research Group for Islet Transplantation, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom 2Oxford Consortium for Islet Transplantation, Oxford Centre for Diabetes, Endocrinology, and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, United Kingdom 3Laboratory for Cancer Drug Delivery and Cell Based Technologies, Faculty of Biotechnology and Food Engineering, Technion, Israel Institute of Technology, Haifa, Israel Aim Islet isolation essentially requires dissociation of islet basement membranes by collagenolytic enzymes. This is associated with reduced islet function and increased cell death. Previous ex-vivo and in-vivo studies demonstrated that individual extracellular matrix proteins (ECMPs) can increase islet survival. As the natural ECM is a tissue-defined complex network we propose a novel concept for creating a specific islet matrix by using the whole pancreatic ECM (WPM). In contrast to previous studies, ECMPs were dissolved in media rather than coating of culture vessel surfaces. Methods Islets, isolated from pancreases of 6 human DBD donors (52±3 years, 28.5±1.5 BMI, 6.4±0.7 hours CIT), were cultured for 4–5 days in hypoxic atmosphere (2% oxygen). Islets were suspended in CMRL 1066 supplemented with 2% FCS and WPM-gel (200 µg/mL) extracted and purified from porcine pancreases. The WPM-gel was compared with a pre-tested combination of human ECMPs composed of 80 µg/mL collagen-IV, 10 µg/mL laminin-521, and 10 µg/mL nidogen-1. Sham-treated islets (STIs) cultured without ECMPs or WPM-gel served as controls. Post-culture characterisation included IEQ yield or islet number (IN), viability (FDA-PI), early plus late apoptosis (annexin V-PI), glucose stimulation index (SI: 2 vs 20 vs 2 mM) and reactive oxygen species production. All parameters were normalised to IEQ, related to pre-culture data if appropriate and presented as mean ± SEM. Statistical analysis was performed by Friedman test and Dunn’s multiple comparison. Results Post-culture recovery was highest when hypoxic human islets were cultured in WPM-gel and compared with STIs (65±10% vs 38±10%, p<0.01). Although fragmentation (IN/IEQ ratio) increased after all treatments, this increase was lowest in the presence of WPM-gel (0.62±0.05 vs 0.80±0.14 vs 0.93±0.27, NS). Pre-culture viability was nearly completely preserved when human ECMPs (99±10% vs 79±10%, p<0.01) or WPM-gel (92±8%, p<0.05) were administered. Reactive oxygen species production in STIs increased nearly three-fold (127±15 AU/IEQ) but was halved in the presence of ECMPs (61±14 AU/IEQ, p<0.01) or WPM-gel (65±18 AU/IEQ, p<0.05). While initial early apoptosis remained stable when human islets were treated with human ECMPs (90±13% vs 136±14%, p<0.01) or WPM-gel (84±10%, p<0.01), apo-necrosis increased substantially in the presence of human ECMPs (172±33%, NS) or WPM-gel (154±195 vs 214±24%, p<0.05). Glucose-stimulated islets did not respond adequately after sham-treatment (SI 0.85±0.14). In contrast, supplementation with human ECMPs (1.29±0.09, p<0.05) or WPM-gel (1.34±0.09, p<0.01) preserved the physiological insulin response during hypoxia. Overall survival, considering the recovery of viable cells only, was increased by human ECMPs (56±8% vs 34±8%, p<0.01) or WPM-gel (58±8%, p<0.01). Conclusion This initial study presents a new approach to protect human islets from hypoxia-induced damage by supplementing culture media with selected ECMPs or with the whole pancreatic ECM. We assume, that the outcome of our approach will be further improved when the ECM is extracted from human pancreases. These promising findings can be used to develop advanced culture media and innovative encapsulation techniques to protect transplanted islets.

AbstractSmoking is a risk factor for periodontal disease, and a cause of oral microbiome dysbiosis. While this has been evaluated for traditional cigarette smoking, there is limited research on the effect of other tobacco types on the oral microbiome. This study investigates subgingival microbiome composition in smokers of different tobacco types and their effect on periodontal health. Subgingival plaques were collected from 40 individuals, including smokers of either cigarettes, medwakh, or shisha, and non-smokers seeking dental treatment at the University Dental Hospital in Sharjah, United Arab Emirates. The entire (~ 1500 bp) 16S rRNA bacterial gene was fully amplified and sequenced using Oxford Nanopore technology. Subjects were compared for the relative abundance and diversity of subgingival microbiota, considering smoking and periodontal condition. The relative abundances of several pathogens were significantly higher among smokers, such as Prevotella denticola and Treponema sp. OMZ 838 in medwakh smokers, Streptococcus mutans and Veillonella dispar in cigarette smokers, Streptococcus sanguinis and Tannerella forsythia in shisha smokers. Subgingival microbiome of smokers was altered even in subjects with no or mild periodontitis, probably making them more prone to severe periodontal diseases. Microbiome profiling can be a useful tool for periodontal risk assessment. Further studies are recommended to investigate the impact of tobacco cessation on periodontal disease progression and oral microbiome.

OBJECTIVE Crouzon syndrome with acanthosis nigricans (CAN) is a rare and clinically complex subtype of Crouzon syndrome. At three craniofacial centers, this multicenter study was undertaken to assess clinical signs in relation to the required interventions and treatment course in patients with CAN. METHODS A retrospective cohort study of CAN was performed to obtain information about the clinical treatment course of these patients. Three centers participated: Erasmus Medical Centre, Rotterdam, the Netherlands; John Radcliffe Hospital, Oxford, United Kingdom; and Hôpital Necker-Enfants Malades, Paris, France. RESULTS Nineteen patients (5 males, 14 females) were included in the study. All children were operated on, with a mean of 2.2 surgeries per patient (range 1–6). Overall, the following procedures were performed: 23 vault expansions, 10 monobloc corrections, 6 midface surgeries, 11 foramen magnum decompressions, 29 CSF-diverting surgeries, 23 shunt-related interventions, and 6 endoscopic third ventriculostomies, 3 of which subsequently required a shunt. CONCLUSIONS This study demonstrates that patients with the mutation c.1172C>A (p.Ala391Glu) in the FGFR3 gene have a severe disease trajectory, requiring multiple surgical procedures. The timing and order of interventions have changed among patients and centers. It was not possible to differentiate the effect of a more severe clinical presentation from the effect of treatment order on outcome.

Lohmann 1/M. Pool 2, K. Rozenberg 3, M. Eijken 4, U. Møldrup 5, B.K. Møller 6, J.M. Sierra Parraga 7, M. Hoogduijn 7, L. Lo Faro 3, C. Moers 2, J. Hunter 3, A.K. Keller 1, H. Leuvenink 2, C.C. Baan 7, R.J. Ploeg 3, B. Jespersen 1 Department of Clinical Medicine, Aarhus University, Aarhus, Denmark Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark Department of Urology, Aarhus University Hospital, Aarhus, Denmark Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark Department of Internal Medicine, Nephrology and Transplantation, Erasmus MC, University Medical Center, Rotterdam, the Netherlands Introduction Marginal kidneys are increasingly being accepted to decrease waiting time for a transplant. Normothermic machine perfusion (NMP) is a technique that allows delivery of therapies that may help condition or repair the organ prior to transplantation. Mesenchymal stromal cells (MSC) may be able to ameliorate ischaemia reperfusion injury as they possess potent anti-inflammatory and regenerative properties. We investigated the safety and effect of MSCs administered during ex vivo NMP prior to transplantation in a pig auto-transplant model of donation after circulatory death. Methods Porcine kidneys subjected to 75 min warm ischaemia were retrieved and preserved for 14h by oxygenated HMP (oxHMP) and 4h NMP and then auto-transplantation. Kidneys were randomised to three different intervention strategies (n=7 per group): following 1h NMP, either a vehicle (NMP), 10 million pig MSC (NMP+pMSC) or 10 million human MSC (NMP+hMSC) were intra-arterially infused. The NMP groups were all compared to a control group, where kidneys were only preserved with oxHMP. The pig was re-anaesthetised, the contralateral kidney was removed and the treated kidney was auto-transplanted and the animals were recovered for 14 days. Results Renal blood flow during NMP was no different between the groups (p=0.0685). Post-transplant plasma creatinine increased in all groups but there were no significant differences between the groups (p=0.517). Plasma kidney injury biomarker NGAL was significantly higher in the NMP+pMSC group compared to the NMP (p=0.003) and NMP+hMSC (p=0.017) groups at day 14. On day 14, mGFR significantly improved in the NMP group compared to the control (55 ± 3 vs 42 ± 12 ml/min, p=0.025). No differences in GFR were observed on day 14 in the other groups (NMP+pMSC, p=0.090 and NMP+hMSC, p=0.387). MSC were detectable in biopsies of MSC treated kidney after NMP and post-transplantation. Conclusion NMP alone improved renal graft function compared to oxHMP of DCD kidneys post-transplant. The method of MSC administration during NMP proved to be safe, however in this model MSC treatment did not improve renal function. Nevertheless viable MSC remained detectable in the transplanted kidney at postoperative day 14 which may have an effect on longer term outcomes.

Abstract Objective To assess the association between covid-19 vaccines and risk of thrombocytopenia and thromboembolic events in England among adults. Design Self-controlled case series study using national data on covid-19 vaccination and hospital admissions. Setting Patient level data were obtained for approximately 30 million people vaccinated in England between 1 December 2020 and 24 April 2021. Electronic health records were linked with death data from the Office for National Statistics, SARS-CoV-2 positive test data, and hospital admission data from the United Kingdom’s health service (NHS). Participants 29 121 633 people were vaccinated with first doses (19 608 008 with Oxford-AstraZeneca (ChAdOx1 nCoV-19) and 9 513 625 with Pfizer-BioNTech (BNT162b2 mRNA)) and 1 758 095 people had a positive SARS-CoV-2 test. People aged ≥16 years who had first doses of the ChAdOx1 nCoV-19 or BNT162b2 mRNA vaccines and any outcome of interest were included in the study. Main outcome measures The primary outcomes were hospital admission or death associated with thrombocytopenia, venous thromboembolism, and arterial thromboembolism within 28 days of three exposures: first dose of the ChAdOx1 nCoV-19 vaccine; first dose of the BNT162b2 mRNA vaccine; and a SARS-CoV-2 positive test. Secondary outcomes were subsets of the primary outcomes: cerebral venous sinus thrombosis (CVST), ischaemic stroke, myocardial infarction, and other rare arterial thrombotic events. Results The study found increased risk of thrombocytopenia after ChAdOx1 nCoV-19 vaccination (incidence rate ratio 1.33, 95% confidence interval 1.19 to 1.47 at 8-14 days) and after a positive SARS-CoV-2 test (5.27, 4.34 to 6.40 at 8-14 days); increased risk of venous thromboembolism after ChAdOx1 nCoV-19 vaccination (1.10, 1.02 to 1.18 at 8-14 days) and after SARS-CoV-2 infection (13.86, 12.76 to 15.05 at 8-14 days); and increased risk of arterial thromboembolism after BNT162b2 mRNA vaccination (1.06, 1.01 to 1.10 at 15-21 days) and after SARS-CoV-2 infection (2.02, 1.82 to 2.24 at 15-21 days). Secondary analyses found increased risk of CVST after ChAdOx1 nCoV-19 vaccination (4.01, 2.08 to 7.71 at 8-14 days), after BNT162b2 mRNA vaccination (3.58, 1.39 to 9.27 at 15-21 days), and after a positive SARS-CoV-2 test; increased risk of ischaemic stroke after BNT162b2 mRNA vaccination (1.12, 1.04 to 1.20 at 15-21 days) and after a positive SARS-CoV-2 test; and increased risk of other rare arterial thrombotic events after ChAdOx1 nCoV-19 vaccination (1.21, 1.02 to 1.43 at 8-14 days) and after a positive SARS-CoV-2 test. Conclusion Increased risks of haematological and vascular events that led to hospital admission or death were observed for short time intervals after first doses of the ChAdOx1 nCoV-19 and BNT162b2 mRNA vaccines. The risks of most of these events were substantially higher and more prolonged after SARS-CoV-2 infection than after vaccination in the same population.

The term “coffee palace” was primarily used in Australia to describe the temperance hotels that were built in the last decades of the 19th century, although there are references to the term also being used to a lesser extent in the United Kingdom (Denby 174). Built in response to the worldwide temperance movement, which reached its pinnacle in the 1880s in Australia, coffee palaces were hotels that did not serve alcohol. This was a unique time in Australia’s architectural development as the economic boom fuelled by the gold rush in the 1850s, and the demand for ostentatious display that gathered momentum during the following years, afforded the use of richly ornamental High Victorian architecture and resulted in very majestic structures; hence the term “palace” (Freeland 121). The often multi-storied coffee palaces were found in every capital city as well as regional areas such as Geelong and Broken Hill, and locales as remote as Maria Island on the east coast of Tasmania. Presented as upholding family values and discouraging drunkenness, the coffee palaces were most popular in seaside resorts such as Barwon Heads in Victoria, where they catered to families. Coffee palaces were also constructed on a grand scale to provide accommodation for international and interstate visitors attending the international exhibitions held in Sydney (1879) and Melbourne (1880 and 1888). While the temperance movement lasted well over 100 years, the life of coffee palaces was relatively short-lived. Nevertheless, coffee palaces were very much part of Australia’s cultural landscape. In this article, I examine the rise and demise of coffee palaces associated with the temperance movement and argue that coffee palaces established in the name of abstinence were modelled on the coffee houses that spread throughout Europe and North America in the 17th and 18th centuries during the Enlightenment—a time when the human mind could be said to have been liberated from inebriation and the dogmatic state of ignorance. The Temperance Movement At a time when newspapers are full of lurid stories about binge-drinking and the alleged ill-effects of the liberalisation of licensing laws, as well as concerns over the growing trend of marketing easy-to-drink products (such as the so-called “alcopops”) to teenagers, it is difficult to think of a period when the total suppression of the alcohol trade was seriously debated in Australia. The cause of temperance has almost completely vanished from view, yet for well over a century—from 1830 to the outbreak of the Second World War—the control or even total abolition of the liquor trade was a major political issue—one that split the country, brought thousands onto the streets in demonstrations, and influenced the outcome of elections. Between 1911 and 1925 referenda to either limit or prohibit the sale of alcohol were held in most States. While moves to bring about abolition failed, Fitzgerald notes that almost one in three Australian voters expressed their support for prohibition of alcohol in their State (145). Today, the temperance movement’s platform has largely been forgotten, killed off by the practical example of the United States, where prohibition of the legal sale of alcohol served only to hand control of the liquor traffic to organised crime. Coffee Houses and the Enlightenment Although tea has long been considered the beverage of sobriety, it was coffee that came to be regarded as the very antithesis of alcohol. When the first coffee house opened in London in the early 1650s, customers were bewildered by this strange new drink from the Middle East—hot, bitter, and black as soot. But those who tried coffee were, reports Ellis, soon won over, and coffee houses were opened across London, Oxford, and Cambridge and, in the following decades, Europe and North America. Tea, equally exotic, entered the English market slightly later than coffee (in 1664), but was more expensive and remained a rarity long after coffee had become ubiquitous in London (Ellis 123-24). The impact of the introduction of coffee into Europe during the seventeenth century was particularly noticeable since the most common beverages of the time, even at breakfast, were weak “small beer” and wine. Both were safer to drink than water, which was liable to be contaminated. Coffee, like beer, was made using boiled water and, therefore, provided a new and safe alternative to alcoholic drinks. There was also the added benefit that those who drank coffee instead of alcohol began the day alert rather than mildly inebriated (Standage 135). It was also thought that coffee had a stimulating effect upon the “nervous system,” so much so that the French called coffee une boisson intellectuelle (an intellectual beverage), because of its stimulating effect on the brain (Muskett 71). In Oxford, the British called their coffee houses “penny universities,” a penny then being the price of a cup of coffee (Standage 158). Coffee houses were, moreover, more than places that sold coffee. Unlike other institutions of the period, rank and birth had no place (Ellis 59). The coffee house became the centre of urban life, creating a distinctive social culture by treating all customers as equals. Egalitarianism, however, did not extend to women—at least not in London. Around its egalitarian (but male) tables, merchants discussed and conducted business, writers and poets held discussions, scientists demonstrated experiments, and philosophers deliberated ideas and reforms. For the price of a cup (or “dish” as it was then known) of coffee, a man could read the latest pamphlets and newsletters, chat with other patrons, strike business deals, keep up with the latest political gossip, find out what other people thought of a new book, or take part in literary or philosophical discussions. Like today’s Internet, Twitter, and Facebook, Europe’s coffee houses functioned as an information network where ideas circulated and spread from coffee house to coffee house. In this way, drinking coffee in the coffee house became a metaphor for people getting together to share ideas in a sober environment, a concept that remains today. According to Standage, this information network fuelled the Enlightenment (133), prompting an explosion of creativity. Coffee houses provided an entirely new environment for political, financial, scientific, and literary change, as people gathered, discussed, and debated issues within their walls. Entrepreneurs and scientists teamed up to form companies to exploit new inventions and discoveries in manufacturing and mining, paving the way for the Industrial Revolution (Standage 163). The stock market and insurance companies also had their birth in the coffee house. As a result, coffee was seen to be the epitome of modernity and progress and, as such, was the ideal beverage for the Age of Reason. By the 19th century, however, the era of coffee houses had passed. Most of them had evolved into exclusive men’s clubs, each geared towards a certain segment of society. Tea was now more affordable and fashionable, and teahouses, which drew clientele from both sexes, began to grow in popularity. Tea, however, had always been Australia’s most popular non-alcoholic drink. Tea (and coffee) along with other alien plants had been part of the cargo unloaded onto Australian shores with the First Fleet in 1788. Coffee, mainly from Brazil and Jamaica, remained a constant import but was taxed more heavily than tea and was, therefore, more expensive. Furthermore, tea was much easier to make than coffee. To brew tea, all that is needed is to add boiling water, coffee, in contrast, required roasting, grinding and brewing. According to Symons, until the 1930s, Australians were the largest consumers of tea in the world (19). In spite of this, and as coffee, since its introduction into Europe, was regarded as the antidote to alcohol, the temperance movement established coffee palaces. In the early 1870s in Britain, the temperance movement had revived the coffee house to provide an alternative to the gin taverns that were so attractive to the working classes of the Industrial Age (Clarke 5). Unlike the earlier coffee house, this revived incarnation provided accommodation and was open to men, women and children. “Cheap and wholesome food,” was available as well as reading rooms supplied with newspapers and periodicals, and games and smoking rooms (Clarke 20). In Australia, coffee palaces did not seek the working classes, as clientele: at least in the cities they were largely for the nouveau riche. Coffee Palaces The discovery of gold in 1851 changed the direction of the Australian economy. An investment boom followed, with an influx of foreign funds and English banks lending freely to colonial speculators. By the 1880s, the manufacturing and construction sectors of the economy boomed and land prices were highly inflated. Governments shared in the wealth and ploughed money into urban infrastructure, particularly railways. Spurred on by these positive economic conditions and the newly extended inter-colonial rail network, international exhibitions were held in both Sydney and Melbourne. To celebrate modern technology and design in an industrial age, international exhibitions were phenomena that had spread throughout Europe and much of the world from the mid-19th century. According to Davison, exhibitions were “integral to the culture of nineteenth century industrialising societies” (158). In particular, these exhibitions provided the colonies with an opportunity to demonstrate to the world their economic power and achievements in the sciences, the arts and education, as well as to promote their commerce and industry. Massive purpose-built buildings were constructed to house the exhibition halls. In Sydney, the Garden Palace was erected in the Botanic Gardens for the 1879 Exhibition (it burnt down in 1882). In Melbourne, the Royal Exhibition Building, now a World Heritage site, was built in the Carlton Gardens for the 1880 Exhibition and extended for the 1888 Centennial Exhibition. Accommodation was required for the some one million interstate and international visitors who were to pass through the gates of the Garden Palace in Sydney. To meet this need, the temperance movement, keen to provide alternative accommodation to licensed hotels, backed the establishment of Sydney’s coffee palaces. The Sydney Coffee Palace Hotel Company was formed in 1878 to operate and manage a number of coffee palaces constructed during the 1870s. These were designed to compete with hotels by “offering all the ordinary advantages of those establishments without the allurements of the drink” (Murdoch). Coffee palaces were much more than ordinary hotels—they were often multi-purpose or mixed-use buildings that included a large number of rooms for accommodation as well as ballrooms and other leisure facilities to attract people away from pubs. As the Australian Town and Country Journal reveals, their services included the supply of affordable, wholesome food, either in the form of regular meals or occasional refreshments, cooked in kitchens fitted with the latest in culinary accoutrements. These “culinary temples” also provided smoking rooms, chess and billiard rooms, and rooms where people could read books, periodicals and all the local and national papers for free (121). Similar to the coffee houses of the Enlightenment, the coffee palaces brought businessmen, artists, writers, engineers, and scientists attending the exhibitions together to eat and drink (non-alcoholic), socialise and conduct business. The Johnson’s Temperance Coffee Palace located in York Street in Sydney produced a practical guide for potential investors and businessmen titled International Exhibition Visitors Pocket Guide to Sydney. It included information on the location of government departments, educational institutions, hospitals, charitable organisations, and embassies, as well as a list of the tariffs on goods from food to opium (1–17). Women, particularly the Woman’s Christian Temperance Union (WCTU) were a formidable force in the temperance movement (intemperance was generally regarded as a male problem and, more specifically, a husband problem). Murdoch argues, however, that much of the success of the push to establish coffee palaces was due to male politicians with business interests, such as the one-time Victorian premiere James Munro. Considered a stern, moral church-going leader, Munro expanded the temperance movement into a fanatical force with extraordinary power, which is perhaps why the temperance movement had its greatest following in Victoria (Murdoch). Several prestigious hotels were constructed to provide accommodation for visitors to the international exhibitions in Melbourne. Munro was responsible for building many of the city’s coffee palaces, including the Victoria (1880) and the Federal Coffee Palace (1888) in Collins Street. After establishing the Grand Coffee Palace Company, Munro took over the Grand Hotel (now the Windsor) in 1886. Munro expanded the hotel to accommodate some of the two million visitors who were to attend the Centenary Exhibition, renamed it the Grand Coffee Palace, and ceremoniously burnt its liquor licence at the official opening (Murdoch). By 1888 there were more than 50 coffee palaces in the city of Melbourne alone and Munro held thousands of shares in coffee palaces, including those in Geelong and Broken Hill. With its opening planned to commemorate the centenary of the founding of Australia and the 1888 International Exhibition, the construction of the Federal Coffee Palace, one of the largest hotels in Australia, was perhaps the greatest monument to the temperance movement. Designed in the French Renaissance style, the façade was embellished with statues, griffins and Venus in a chariot drawn by four seahorses. The building was crowned with an iron-framed domed tower. New passenger elevators—first demonstrated at the Sydney Exhibition—allowed the building to soar to seven storeys. According to the Federal Coffee Palace Visitor’s Guide, which was presented to every visitor, there were three lifts for passengers and others for luggage. Bedrooms were located on the top five floors, while the stately ground and first floors contained majestic dining, lounge, sitting, smoking, writing, and billiard rooms. There were electric service bells, gaslights, and kitchens “fitted with the most approved inventions for aiding proficients [sic] in the culinary arts,” while the luxury brand Pears soap was used in the lavatories and bathrooms (16–17). In 1891, a spectacular financial crash brought the economic boom to an abrupt end. The British economy was in crisis and to meet the predicament, English banks withdrew their funds in Australia. There was a wholesale collapse of building companies, mortgage banks and other financial institutions during 1891 and 1892 and much of the banking system was halted during 1893 (Attard). Meanwhile, however, while the eastern States were in the economic doldrums, gold was discovered in 1892 at Coolgardie and Kalgoorlie in Western Australia and, within two years, the west of the continent was transformed. As gold poured back to the capital city of Perth, the long dormant settlement hurriedly caught up and began to emulate the rest of Australia, including the construction of ornately detailed coffee palaces (Freeman 130). By 1904, Perth had 20 coffee palaces. When the No. 2 Coffee Palace opened in Pitt Street, Sydney, in 1880, the Australian Town and Country Journal reported that coffee palaces were “not only fashionable, but appear to have acquired a permanent footing in Sydney” (121). The coffee palace era, however, was relatively short-lived. Driven more by reformist and economic zeal than by good business sense, many were in financial trouble when the 1890’s Depression hit. Leading figures in the temperance movement were also involved in land speculation and building societies and when these schemes collapsed, many, including Munro, were financially ruined. Many of the palaces closed or were forced to apply for liquor licences in order to stay afloat. Others developed another life after the temperance movement’s influence waned and the coffee palace fad faded, and many were later demolished to make way for more modern buildings. The Federal was licensed in 1923 and traded as the Federal Hotel until its demolition in 1973. The Victoria, however, did not succumb to a liquor licence until 1967. The Sydney Coffee Palace in Woolloomooloo became the Sydney Eye Hospital and, more recently, smart apartments. Some fine examples still survive as reminders of Australia’s social and cultural heritage. The Windsor in Melbourne’s Spring Street and the Broken Hill Hotel, a massive three-story iconic pub in the outback now called simply “The Palace,” are some examples. Tea remained the beverage of choice in Australia until the 1950s when the lifting of government controls on the importation of coffee and the influence of American foodways coincided with the arrival of espresso-loving immigrants. As Australians were introduced to the espresso machine, the short black, the cappuccino, and the café latte and (reminiscent of the Enlightenment), the post-war malaise was shed in favour of the energy and vigour of modernist thought and creativity, fuelled in at least a small part by caffeine and the emergent café culture (Teffer). Although the temperance movement’s attempt to provide an alternative to the ubiquitous pubs failed, coffee has now outstripped the consumption of tea and today’s café culture ensures that wherever coffee is consumed, there is the possibility of a continuation of the Enlightenment’s lively discussions, exchange of news, and dissemination of ideas and information in a sober environment. References Attard, Bernard. “The Economic History of Australia from 1788: An Introduction.” EH.net Encyclopedia. 5 Feb. (2012) ‹http://eh.net/encyclopedia/article/attard.australia›. Blainey, Anna. “The Prohibition and Total Abstinence Movement in Australia 1880–1910.” Food, Power and Community: Essays in the History of Food and Drink. Ed. Robert Dare. Adelaide: Wakefield Press, 1999. 142–52. Boyce, Francis Bertie. “Shall I Vote for No License?” An address delivered at the Convention of the Parramatta Branch of New South Wales Alliance, 3 September 1906. 3rd ed. Parramatta: New South Wales Alliance, 1907. Clarke, James Freeman. Coffee Houses and Coffee Palaces in England. Boston: George H. Ellis, 1882. “Coffee Palace, No. 2.” Australian Town and Country Journal. 17 Jul. 1880: 121. Davison, Graeme. “Festivals of Nationhood: The International Exhibitions.” Australian Cultural History. Eds. S. L. Goldberg and F. B. Smith. Cambridge: Cambridge UP, 1989. 158–77. Denby, Elaine. Grand Hotels: Reality and Illusion. London: Reaktion Books, 2002. Ellis, Markman. The Coffee House: A Cultural History. London: Weidenfeld & Nicolson, 2004. Federal Coffee Palace. The Federal Coffee Palace Visitors’ Guide to Melbourne, Its Suburbs, and Other Parts of the Colony of Victoria: Views of the Principal Public and Commercial Buildings in Melbourne, With a Bird’s Eye View of the City; and History of the Melbourne International Exhibition of 1880, etc. Melbourne: Federal Coffee House Company, 1888. Fitzgerald, Ross, and Trevor Jordan. Under the Influence: A History of Alcohol in Australia. Sydney: Harper Collins, 2009. Freeland, John. The Australian Pub. Melbourne: Sun Books, 1977. Johnson’s Temperance Coffee Palace. International Exhibition Visitors Pocket Guide to Sydney, Restaurant and Temperance Hotel. Sydney: Johnson’s Temperance Coffee Palace, 1879. Mitchell, Ann M. “Munro, James (1832–1908).” Australian Dictionary of Biography. Canberra: National Centre of Biography, Australian National U, 2006-12. 5 Feb. 2012 ‹http://adb.anu.edu.au/biography/munro-james-4271/text6905›. Murdoch, Sally. “Coffee Palaces.” Encyclopaedia of Melbourne. Eds. Andrew Brown-May and Shurlee Swain. 5 Feb. 2012 ‹http://www.emelbourne.net.au/biogs/EM00371b.htm›. Muskett, Philip E. The Art of Living in Australia. New South Wales: Kangaroo Press, 1987. Standage, Tom. A History of the World in 6 Glasses. New York: Walker & Company, 2005. Sydney Coffee Palace Hotel Company Limited. Memorandum of Association of the Sydney Coffee Palace Hotel Company, Ltd. Sydney: Samuel Edward Lees, 1879. Symons, Michael. One Continuous Picnic: A Gastronomic History of Australia. Melbourne: Melbourne UP, 2007. Teffer, Nicola. Coffee Customs. Exhibition Catalogue. Sydney: Customs House, 2005.

Human history has witnessed varied surveillance and counter-surveillance activities from time immemorial. Human beings could not surveille others effectively and accurately without the technology of their era. Technology is a tool that can empower both people and governments. The outcomes are different based on the users’ intentions and aims. 2,500 years ago, Sun Tzu noted that ‘If you know both yourself and your enemy, you can win numerous (literally, "a hundred") battles without jeopardy’. His words still ring true. To be a good surveiller and counter-surveiller it is essential to know both sides, and in order to be good at these activities access to technology is vital. There is no doubt that knowledge is power, and without technology to access the information, it is impossible to be powerful. As we become more expert at technology, we will learn what makes surveillance and counter-surveillance more effective, and will be more powerful.“Surveillance” is one of the most important aspects of living in the convergent media environment. This essay illustrates government surveillance and counter-surveillance during the Iranian Green Movement (2009) on social and mobile media. The Green Movement refers to a non-violent movement that arose after the disputed presidential election on June 2009. After that Iran was facing its most serious political crisis since the 1979 revolution. Claims of vote fraud triggered massive street protests. Many took to the streets with “Green” signs, chanting slogans such as ‘the government lied’, and ‘where is my vote?’ There is no doubt that social and mobile media has played an important role in Iran’s contemporary politics. According to Internet World Stats (IWS) Internet users in 2009 account for approximately 48.5 per cent of the population of Iran. In 2009, Iran had 30.2 million mobile phone users (Freedom House), and 72 cellular subscriptions for every 100 people (World Bank). Today, while Iran has the 19th-largest population in the world, its blogosphere holds the third spot in terms of number of users, just behind the United States and China (Beth Elson et al.). In this essay the use of social and mobile media (technology) is not debated, but the extent of this use, and who, why and how it is used, is clearly scrutinised.Visibility and Surveillance There have been different kinds of surveillance for a very long time. However, all types of surveillance are based on the notion of “visibility”. Previous studies show that visibility is not a new term (Foucault Discipline). The new things in the new era, are its scale, scope and complicated ways to watch others without being watched, which are not limited to a specific time, space and group, and are completely different from previous instruments for watching (Andrejevic). As Meikle and Young (146) have mentioned ‘networked digital media bring with them a new kind of visibility’, based on different kinds of technology. Internet surveillance has important implications in politics to control, protect, and influence (Marx Ethics; Castells; Fuchs Critique). Surveillance has been improved during its long history, and evolved from very simple spying and watching to complicated methods of “iSpy” (Andrejevic). To understand the importance of visibility and its relationship with surveillance, it is essential to study visibility in conjunction with the notion of “panopticon” and its contradictory functions. Foucault uses Bentham's notion of panopticon that carries within itself visibility and transparency to control others. “Gaze” is a central term in Bentham’s view. ‘Bentham thinks of a visibility organised entirely around a dominating, overseeing gaze’ (Foucault Eye). Moreover, Thomson (Visibility 11) notes that we are living in the age of ‘normalizing the power of the gaze’ and it is clear that the influential gaze is based on powerful means to see others.Lyon (Surveillance 2) explains that ‘surveillance is any collection and processing of personal data, whether identifiable or not, for the purpose of influencing or managing those whose data have been granted…’. He mentions that today the most important means of surveillance reside in computer power which allows collected data to be sorted, matched, retrieved, processed, marketed and circulated.Nowadays, the Internet has become ubiquitous in many parts of the world. So, the changes in people’s interactions have influenced their lives. Fuchs (Introduction 15) argues that ‘information technology enables surveillance at a distance…in real time over networks at high transmission speed’. Therefore, visibility touches different aspects of people’s lives and living in a “glasshouse” has caused a lot of fear and anxiety about privacy.Iran’s Green Movement is one of many cases for studying surveillance and counter-surveillance technologies in social and mobile media. Government Surveillance on Social and Mobile Media in Iran, 2009 In 2009 the Iranian government controlled technology that allowed them to monitor, track, and limit access to the Internet, social media and mobiles communication, which has resulted in the surveillance of Green Movement’s activists. The Iranian government had improved its technical capabilities to monitor the people’s behavior on the Internet long before the 2009 election. The election led to an increase in online surveillance. Using social media the Iranian government became even more powerful than it was before the election. Social media was a significant factor in strengthening the government’s power. In the months after the election the virtual atmosphere became considerably more repressive. The intensified filtering of the Internet and implementation of more advanced surveillance systems strengthened the government’s position after the election. The Open Net Initiative revealed that the Internet censorship system in Iran is one of the most comprehensive and sophisticated censorship systems in the world. It emphasized that ‘Advances in domestic technical capacity have contributed to the implementation of a centralized filtering strategy and a reduced reliance on Western technologies’.On the other hand, the authorities attempted to block all access to political blogs (Jaras), either through cyber-security methods or through threats (Tusa). The Centre for Investigating Organized Cyber Crimes, which was founded in 2007 partly ‘to investigate and confront social and economic offenses on the Internet’ (Cyber Police), became increasingly important over the course of 2009 as the government combated the opposition’s online activities (Beth Elson et al. 16). Training of "senior Internet lieutenants" to confront Iran's "virtual enemies online" was another attempt that the Intelligence minister announced following the protests (Iran Media Program).In 2009 the Iranian government enacted the Computer Crime Law (Jaras). According to this law the Committee in Charge of Determining Unauthorized Websites is legally empowered to identify sites that carry forbidden content and report that information to TCI and other major ISPs for blocking (Freedom House). In the late fall of 2009, the government started sending threatening and warning text messages to protesters about their presence in the protests (BBC). Attacking, blocking, hacking and hijacking of the domain names of some opposition websites such as Jaras and Kaleme besides a number of non-Iranian sites such as Twitter were among the other attempts of the Iranian Cyber Army (Jaras).It is also said that the police and security forces arrested dissidents identified through photos and videos posted on the social media that many imagined had empowered them. Furthermore, the online photos of the active protesters were posted on different websites, asking people to identify them (Valizadeh).In late June 2009 the Iranian government was intentionally permitting Internet traffic to and from social networking sites such as Facebook and Twitter so that it could use a sophisticated practice called Deep Packet Inspection (DPI) to collect information about users. It was reportedly also applying the same technology to monitor mobile phone communications (Beth Elson et al. 15).On the other hand, to cut communication between Iranians inside and outside the country, Iran slowed down the Internet dramatically (Jaras). Iran also blocked access to Facebook, YouTube, Wikipedia, Twitter and many blogs before, during and after the protests. Moreover, in 2009, text message services were shut down for over 40 days, and mobile phone subscribers could not send or receive text messages regardless of their mobile carriers. Subsequently it was disrupted on a temporary basis immediately before and during key protests days.It was later discovered that the Nokia Siemens Network provided the government with surveillance technologies (Wagner; Iran Media Program). The Iranian government built a complicated system that enabled it to monitor, track and intercept what was said on mobile phones. Nokia Siemens Network confirmed it supplied Iran with the technology needed to monitor, control, and read local telephone calls [...] The product allowed authorities to monitor any communications across a network, including voice calls, text messaging, instant messages, and web traffic (Cellan-Jones). Media sources also reported that two Chinese companies, Huawei and ZTE, provided surveillance technologies to the government. The Nic Payamak and Saman Payamak websites, that provide mass text messaging services, also reported that operator Hamrah Aval commonly blocked texts with words such as meeting, location, rally, gathering, election and parliament (Iran Media Program). Visibility and Counter-Surveillance The panopticon is not limited to the watchers. Similarly, new kinds of panopticon and visibility are not confined to government surveillance. Foucault points out that ‘the seeing machine was once a sort of dark room into which individuals spied; it has become a transparent building in which the exercise of power may be supervised by society as a whole’ (Discipline 207). What is important is Foucault's recognition that transparency, not only of those who are being observed but also of those who are observing, is central to the notion of the panopticon (Allen) and ‘any member of society will have the right to come and see with his own eyes how schools, hospitals, factories, and prisons function’ (Foucault, Discipline 207). Counter-surveillance is the process of detecting and mitigating hostile surveillance (Burton). Therefore, while the Internet is a surveillance instrument that enables governments to watch people, it also improves the capacity to counter-surveille, and draws public attention to governments’ injustice. As Castells (185) notes the Internet could be used by citizens to watch their government as an instrument of control, information, participation, and even decision-making, from the bottom up.With regards to the role of citizens in counter-surveillance we can draw on Jay Rosen’s view of Internet users as ‘the people formerly known as the audience’. In counter-surveillance it can be said that passive citizens (formerly the audience) have turned into active citizens. And this change was becoming impossible without mobile and social media platforms. These new techniques and technologies have empowered people and given them the opportunity to have new identities. When Thompson wrote ‘the exercise of power in modern societies remains in many ways shrouded in secrecy and hidden from the public gaze’ (Media 125), perhaps he could not imagine that one day people can gaze at the politicians, security forces and the police through the use of the Internet and mobile devices.Furthermore, while access to mobile media allows people to hold authorities accountable for their uses and abuses of power (Breen 183), social media can be used as a means of representation, organization of collective action, mobilization, and drawing attention to police brutality and reasons for political action (Gerbaudo).There is no doubt that having creativity and using alternative platforms are important aspects in counter-surveillance. For example, images of Lt. Pike “Pepper Spray Cop” from the University of California became the symbol of the senselessness of police brutality during the Occupy Movement (Shaw). Iranians’ Counter-Surveillance on Social and Mobile Media, 2009 Iran’s Green movement (2009) triggered a lot of discussions about the role of technology in social movements. In this regard, there are two notable attitudes about the role of technology: techno-optimistic (Shriky and Castells) and techno-pessimistic (Morozov and Gladwell) views should be taken into account. While techno-optimists overrated the role of social media, techno-pessimists underestimated its role. However, there is no doubt that technology has played a great role as a counter-surveillance tool amongst Iranian people in Iran’s contemporary politics.Apart from the academic discussions between techno-optimists and techno-pessimists, there have been numerous debates about the role of new technologies in Iran during the Green Movement. This subject has received interest from different corners of the world, including Western countries, Iranian authorities, opposition groups, and also some NGOs. However, its role as a means of counter-surveillance has not received adequate attention.As the tools of counter-surveillance are more or less the tools of surveillance, protesters learned from the government to use the same techniques to challenge authority on social media.Establishing new websites (such as JARAS, RASA, Kalemeh, and Iran green voice) or strengthening some previous ones (such as Saham, Emrooz, Norooz), also activating different platforms such as Facebook, Twitter, and YouTube accounts to broadcast the voice of the Iranian Green Movement and neutralize the government’s propaganda were the most important ways to empower supporters of Iran’s Green Movement in counter-surveillance.‘Reporters Without Borders issued a statement, saying that ‘the new media, and particularly social networks, have given populations collaborative tools with which they can change the social order’. It is also mentioned that despite efforts by the Iranian government to prevent any reporting of the protests and due to considerable pressure placed on foreign journalists inside Iran, social media played a significant role in sending the messages and images of the movement to the outside world (Axworthy). However, at that moment, many thought that Twitter performed a liberating role for Iranian dissenters. For example, Western media heralded the Green Movement in Iran as a “Twitter revolution” fuelled by information and communication technologies (ICTs) and social media tools (Carrieri et al. 4). “The Revolution Will Be Twittered” was the first in a series of blog posts published by Andrew Sullivan a few hours after the news of the protests was released.According to the researcher’s observation the numbers of Twitter users inside Iran who tweeted was very limited in 2009 and social media was most useful in the dissemination of information, especially from those inside Iran to outsiders. Mobile phones were mostly influential as an instrument firstly used for producing contents (images and videos) and secondly for the organisation of protests. There were many photos and videos that were filmed by very simple mobile cell phones, uploaded by ordinary people onto YouTube and other platforms. The links were shared many times on Twitter and Facebook and released by mainstream media. The most frequently circulated story from the Iranian protests was a video of Neda Agha-Sultan. Her final moments were captured by some bystanders with mobile phone cameras and rapidly spread across the global media and the Internet. It showed that the camera-phone had provided citizens with a powerful means, allowing for the creation and instant sharing of persuasive personalised eyewitness records with mobile and globalised target populations (Anden-Papadopoulos).Protesters used another technique, DDOS (distributed denial of service attacks), for political protest in cyber space. Anonymous people used DDOS to overload a website with fake requests, making it unavailable for users and disrupting the sites set as targets (McMillan) in effect, shutting down the site. DDOS is an important counter-surveillance activity by grassroots activists or hackers. It was a cyber protest that knocked the main Iranian governmental websites off-line and caused crowdsourcing and false trafficking. Amongst them were Mahmoud Ahmadinejad, Iran's supreme leader’s websites and those which belong to or are close to the government or security forces, including news agencies (Fars, IRNA, Press TV…), the Ministry of Foreign Affairs, the Ministry of Justice, the Police, and the Ministry of the Interior.Moreover, as authorities uploaded the pictures of protesters onto different platforms to find and arrest them, in some cities people started to put the pictures, phone numbers and addresses of members of security forces and plain clothes police officers who attacked them during the protests and asked people to identify and report the others. They also wanted people to send information about suspects who infringed human rights. Conclusion To sum up, visibility, surveillance and counter-surveillance are not new phenomena. What is new is the technology, which increased their complexity. As Foucault (Discipline 200) mentioned ‘visibility is a trap’, so being visible would be the weakness of those who are being surveilled in the power struggle. In the convergent era, in order to be more powerful, both surveillance and counter-surveillance activities aim for more visibility. Although both attempt to use the same means (technology) to trap the other side, the differences are in their subjects, objects, goals and results.While in surveillance, visibility of the many by the few is mostly for the purpose of control and influence in undemocratic ways, in counter-surveillance, the visibility of the few by the many is mostly through democratic ways to secure more accountability and transparency from the governments.As mentioned in the case of Iran’s Green Movement, the scale and scope of visibility are different in surveillance and counter-surveillance. The importance of what Shaw wrote about Sydney occupy counter-surveillance, applies to other places, such as Iran. She has stressed that ‘protesters and police engaged in a dance of technology and surveillance with one another. Both had access to technology, but there were uncertainties about the extent of technology and its proficient use…’In Iran (2009), both sides (government and activists) used technology and benefited from digital networked platforms, but their levels of access and domains of influence were different, which was because the sources of power, information and wealth were divided asymmetrically between them. Creativity was important for both sides to make others more visible, and make themselves invisible. Also, sharing information to make the other side visible played an important role in these two areas. References Alen, David. “The Trouble with Transparency: The Challenge of Doing Journalism Ethics in a Surveillance Society.” Journalism Studies 9.3 (2008): 323-40. 8 Dec. 2013 ‹http://www.tandfonline.com/doi/full/10.1080/14616700801997224#.UqRFSuIZsqN›. Anden-Papadopoulos, Kari. “Citizen Camera-Witnessing: Embodied Political Dissent in the Age of ‘Mediated Mass Self-Communication.’” New Media & Society 16.5 (2014). 753-69. 9 Aug. 2014 ‹http://nms.sagepub.com/content/16/5/753.full.pdf+html›. Andrejevic, Mark. iSpy: Surveillance and Power in the Interactive Era. Lawrence, Kan: UP of Kansas, 2007. Axworthy, Micheal. Revolutionary Iran: A History of the Islamic Republic. London: Penguin Books, 2014. Bentham, Jeremy. Panopticon Postscript. London: T. Payne, 1791. Beth Elson, Sara, Douglas Yeung, Parisa Roshan, S.R. Bohandy, and Alireza Nader. Using Social Media to Gauge Iranian Public Opinion and Mood after the 2009 Election. Santa Monica: RAND Corporation, 2012. 1 Aug. 2014 ‹http://www.rand.org/content/dam/rand/pubs/technical_reports/2012/RAND_TR1161.pdf›. Breen, Marcus. Uprising: The Internet’s Unintended Consequences. Champaign, Ill: Common Ground Pub, 2011. Burton, Fred. “The Secrets of Counter-Surveillance.” Stratfor Global Intelligence. 2007. 19 April 2015 ‹https://www.stratfor.com/secrets_countersurveillance›. Carrieri, Matthew, Ali Karimzadeh Bangi, Saad Omar Khan, and Saffron Suud. After the Green Movement Internet Controls in Iran, 2009-2012. OpenNet Initiative, 2013. 17 Dec. 2013 ‹https://opennet.net/sites/opennet.net/files/iranreport.pdf›. Castells, Manuel. The Internet Galaxy: Reflections on the Internet, Business, and Society. Oxford: Oxford UP: 2001. Cellan-Jones, Rory. “Hi-Tech Helps Iranian Monitoring.” BBC, 2009. 26 July 2014 ‹http://news.bbc.co.uk/1/hi/technology/8112550.stm›. “Cyber Crimes’ List.” Iran: Cyber Police, 2009. 17 July 2014 ‹http://www.cyberpolice.ir/page/2551›. Foucault, Michel. Discipline and Punish: The Birth of the Prison. Trans. Alan Sheridan. Harmondsworth: Penguin, 1977. Foucault, Michel. “The Eye of Power.” 1980. 12 Dec. 2013 ‹https://nbrokaw.files.wordpress.com/2010/12/the-eye-of-power.doc›. Freedom House. “Special Report: Iran.” 2009. 14 June 2014 ‹http://www.sssup.it/UploadDocs/4661_8_A_Special_Report_Iran_Feedom_House_01.pdf›. Fuchs, Christian. “Introduction.” Internet and Surveillance: The Challenges of Web 2.0 and Social Media. Ed. Christian Fuchs. London: Routledge, 2012. 1-28. Fuchs, Christian. “Critique of the Political Economy of Web 2.0 Surveillance.” Internet and Surveillance: The Challenges of Web 2.0 and Social Media. Ed. Christian Fuchs. London: Routledge, 2012. 30-70. Gerbaudo, Paolo. Tweets and the Streets: Social Media and Contemporary Activism. London: Pluto, 2012. “Internet: Iran’s New Imaginary Enemy.” Jaras Mar. 2009. 28 June 2014 ‹http://www.rahesabz.net/print/12143›.Iran Media Program. “Text Messaging as Iran's New Filtering Frontier.” 2013. 25 July 2014 ‹http://www.iranmediaresearch.org/en/blog/227/13/04/25/136›. Internet World Stats News. The Internet Hits 1.5 Billion. 2009. 3 July 2014 ‹ http://www.internetworldstats.com/pr/edi038.htm›. Lyon, David. Surveillance Society: Monitoring Everyday Life. Buckingham: Open UP, 2001. Lyon, David. “9/11, Synopticon, and Scopophilia: Watching and Being Watched.” The New Politics of Surveillance and Visibility. Eds. Richard V. Ericson and Kevin D. Haggerty. Toronto: UP of Toronto, 2006. 35-54. Marx, Gary T. “What’s New about the ‘New Surveillance’? Classify for Change and Continuity.” Surveillance & Society 1.1 (2002): 9-29. McMillan, Robert. “With Unrest in Iran, Cyber-Attacks Begin.” PC World 2009. 17 Apr. 2015 ‹http://www.pcworld.com/article/166714/article.html›. Meikle, Graham, and Sherman Young. Media Convergence: Networked Digital Media in Everyday Life. London: Palgrave Macmillan, 2012. Morozov, Evgeny. “How Dictators Watch Us on the Web.” Prospect 2009. 15 June 2014 ‹http://www.prospectmagazine.co.uk/magazine/how-dictators-watch-us-on-the-web/#.U5wU6ZRdU00›.Open Net. “Iran.” 2009. 26 June 2014 ‹https://opennet.net/research/profiles/iran›. Reporters without Borders. “Web 2.0 versus Control 2.0.” 2010. 27 May 2014 ‹http://en.rsf.org/web-2-0-versus-control-2-0-18-03-2010,36697›.Rosen, Jay. The People Formerly Known as the Audience. 2006. 7 Dec. 2013 ‹http://www.huffingtonpost.com/jay-rosen/the-people-formerly-known_1_b_24113.html›. Shaw, Frances. “'Walls of Seeing': Protest Surveillance, Embodied Boundaries, and Counter-Surveillance at Occupy Sydney.” Transformation 23 (2013). 9 Dec. 2013 ‹http://www.transformationsjournal.org/journal/issue_23/article_04.shtml›. “The Warning of the Iranian Revolutionary Guard Corps (IRGC) to the Weblogs and Websites.” BBC, 2009. 27 July 2014 ‹http://www.bbc.co.uk/persian/iran/2009/06/090617_ka_ir88_sepah_internet.shtml›. Thompson, John B. The Media And Modernity: A Social Theory of the Media. Cambridge: Polity Press, 1995. Thompson, John B. “The New Visibility.” Theory, Culture & Society 22.6 (2005): 31-51. 10 Dec. 2013 ‹http://tcs.sagepub.com/content/22/6/31.full.pdf+html›. Tusa, Felix. “How Social Media Can Shape a Protest Movement: The Cases of Egypt in 2011 and Iran in 2009.” Arab Media and Society 17 (Winter 2013). 15 July 2014 ‹http://www.arabmediasociety.com/index.php?article=816&p=0›. Tzu, Sun. Sun Tzu: The Art of War. S.l.: Pax Librorum Pub. H, 2009. Valizadeh, Reza. “Invitation to the Public Shooting with the Camera.” RFI, 2011. 19 June 2014 ‹http://www.persian.rfi.fr/%D8%AF%D8%B9%D9%88%D8%AA-%D8%A8%D9%87-%D8%B4%D9%84%DB%8C%DA%A9-%D8%B9%D9%85%D9%88%D9%85%DB%8C-%D8%A8%D8%A7-%D8%AF%D9%88%D8%B1%D8%A8%DB%8C%D9%86-%D8%B9%DA%A9%D8%A7%D8%B3%DB%8C-20110307/%D8%A7%DB%8C%D8%B1%D8%A7%D9%86›. Wagner, Ben. Exporting Censorship and Surveillance Technology. Netherlands: Humanist Institute for Co-operation with Developing Countries (Hivos), 2012. 7 July 2014 ‹https://hivos.org/sites/default/files/exporting_censorship_and_surveillance_technology_by_ben_wagner.pdf›. World Bank. Mobile Cellular Subscriptions (per 100 People). The World Bank. N.d. 27 June 2014 ‹http://data.worldbank.org/indicator/IT.CEL.SETS.P2›.

IntroductionIn Britain, hunger is often hidden in the privacy of the home. Yet otherwise private hunger is currently being rendered public and visible in the growing queues at charity-run food banks, where emergency food parcels are distributed directly to those who cannot afford to feed themselves or their families adequately (Downing et al.; Caplan). Food banks, in providing emergency relief to those in need, are responses to crisis moments, actualised through an embodied feeling of hunger that cannot be alleviated. The growing queues at food banks not only render hidden hunger visible, but also serve as reminders of the corporeal vulnerability of the human body to political and socio-economic shifts.A consideration of corporeality allows us to view the world through the lived experiences of the body. Human beings are “creatures of the flesh” who understand and reason, act and interact with their environments through the body (Johnson 81). The growing academic interest in corporeality signifies what Judith Butler calls a “new bodily ontology” (2). However, as Butler highlights, the body is also vulnerable to injury and suffering. An application of this ontology to hunger draws attention to eating as essential to life, so the denial of food poses an existential threat to health and ultimately to survival. The body’s response to threat is the physiological experience of hunger as a craving or longing that is the “most bodily experience of need […] a visceral desire locatable in a void” in which an empty stomach “initiates” a series of sounds and pangs that “call for action” in the form of eating (Anderson 27). Food bank queues serve as visible public reminders of this precariousness and of how social conditions can limit the ability of individuals to feed themselves, and so respond to an existential threat.Corporeal vulnerability made visible elicits responses that support societal interventions to feed the hungry, or that stigmatise hungry people by withdrawing or disparaging what limited support is available. Responses to vulnerability therefore evoke nurture and care or violence and abuse, and so in this sense are ambiguous (Butler; Cavarero). The responses are also normative, shaped by social and cultural understandings of what hunger is, what its causes are, and whether it is seen as originating in personal or societal failings. The stigmatising of individuals by blaming them for their hunger is closely allied to the feelings of shame that lie at the “irreducible absolutist core” of the idea of poverty (Sen 159). Shame is where the “internally felt inadequacies” of the impoverished individual and the “externally inflicted judgments” of society about the hungry body come together in a “co-construction of shame” (Walker et al. 5) that is a key part of the lived experience of hunger. The experience of shame, while common, is far from inevitable and is open to resistance (see Pickett; Foucault); shame can be subverted, turned from the hungry body and onto the society that allows hunger to happen. Who and what are deemed responsible are shaped by shifting ideas and contested understandings of hunger at a particular moment in time (Vernon).This exploration of corporeal vulnerability through food banks as a historically located response to hunger offers an alternative to studies which privilege representations, objectifying the body and “treating it as a discursive, textual, iconographic and metaphorical reality” while neglecting understandings derived from lived experiences and the responses that visible vulnerabilities elicit (Hamilakis 99). The argument made in this paper calls for a critical reconsideration of classic political economy approaches that view hunger in terms of a class struggle against the material conditions that give rise to it, and responses that ultimately led to the construction of the welfare state (Vernon). These political economy approaches, in focusing on the structures that lead to hunger and that respond to it, are more closed than Butler’s notion of ambiguous and constantly changing social responses to corporeal vulnerability. This paper also challenges the dominant tradition of nutrition science, which medicalises hunger. While nutrition science usefully draws attention to the physiological experiences and existential threat posed by acute hunger, the scientific focus on the “anatomical functioning” of the body and the optimising of survival problematically separates eating from the social contexts in which hunger is experienced (Lupton 11, 12; Abbots and Lavis). The focus in this article on the corporeal vulnerability of hunger interweaves contested representations of, and ideas about, hunger with the physiological experience of it, the material conditions that shape it, and the lived experiences of deprivation. Food banks offer a lens onto these experiences and their complexities.Food Banks: Deprivation Made VisibleSince the 1980s, food banks have become the fastest growing charitable organisations in the wealthiest countries of North America, Europe, and Australasia (Riches), but in Britain they are a recent phenomenon. The first opened in 2000, and by 2014, the largest operator, the Trussell Trust, had over 420 franchised food banks, and more recently was opening more than one per week (Lambie-Mumford et al.; Lambie-Mumford and Dowler). British food banks hand out emergency food relief directly to those who cannot afford to feed themselves or their families adequately, and have become new sites where deprivation is materialised through a congregation of hungry people and the distribution of food parcels. The food relief parcels are intended as short-term immediate responses to crisis moments felt within the body when the individual cannot alleviate hunger through their own resources; they are for “emergency use only” to ameliorate individual crisis and acute vulnerability, and are not intended as long-term solutions to sustained, chronic poverty (Perry et al.). The need for food banks has emerged with the continued shrinkage of the welfare state, which for the past half century sought to mediate the impact of changing individual and social circumstances on those deemed to be most vulnerable to the vicissitudes of life. The proliferation of food banks since the 2009 financial crisis and the increased public discourse about them has normalised their presence and naturalised their role in alleviating acute food poverty (Perry et al.).Media images of food bank queues and stacks of tins waiting to be handed out (Glaze; Gore) evoke collective memories from the early twentieth century of hunger marches in protest at government inaction over poverty, long queues at soup kitchens, and the faces of gaunt, unemployed war veterans (Vernon). After the Second World War, the spectre of communism and the expansionist agenda of the Soviet Union meant such images of hunger could become tools in a propaganda war constructed around the failure of the British state to care for its citizens (Field; Clarke et al; Vernon). The 1945 Labour government, elected on a social democratic agenda of reform in an era of food rationing, responded with a “war on want” based on the normative premise that no one should be without food, medical care, shelter, warmth or work. Labour’s response was the construction of the modern welfare state.The welfare state signified a major shift in ideational understandings of hunger. In the seventeenth and eighteenth centuries, ideas about hunger had been rooted in a moralistic account of divine punishment for individual failure (Vernon). Bodily experiences of hunger were seen as instruments for disciplining the indigent into a work ethic appropriate for a modern industrialised economy. The infamous workhouses, finally abolished in 1948, were key sites of deprivation where restrictions on how much food was distributed served to punish or discipline the hungry body into compliance with the dominant work ethic (Vernon; Foucault). However, these ideas shifted in the second half of the nineteenth century as the hungry citizen in Britain (if not in its colonies) was increasingly viewed as a victim of wider forces beyond the control of the individual, and the notion of disciplining the hungry body in workhouses was seen as reprehensible. A humanitarian treatment of hunger replaced a disciplinarian one as a more appropriate response to acute need (Shaw; Vernon). Charitable and reformist organisations proliferated with an agenda to feed, clothe, house, and campaign on behalf of those most deprived, and civil society largely assumed responsibility for those unable to feed themselves. By the early 1900s, ideas about hunger had begun to shift again, and after the Second World War ideational changes were formalised in the welfare state, premised on a view of hunger as due to structural rather than individual failure, hence the need for state intervention encapsulated in the “cradle to grave” mantra of the welfare state, i.e. of consistent care at the point of need for all citizens for their lifetime (see Clarke and Newman; Field; Powell). In this context, the suggestion that Britons could go to bed hungry because they could not afford to feed themselves would be seen as the failure of the “war on want” and of an advanced modern democracy to fulfil its responsibilities for the welfare of its citizens.Since the 1980s, there has been a retreat from these ideas. Successive governments have sought to rein in, reinvent or shrink what they have perceived as a “bloated” welfare state. In their view this has incentivised “dependency” by providing benefits so generous that the supposedly work-shy or “skivers” have no need to seek employment and can fund a diet of takeaways and luxury televisions (Howarth). These stigmatising ideas have, since the 2009 financial crisis and the 2010 election, become more entrenched as the Conservative-led government has sought to renew a neo-liberal agenda to shrink the welfare state, and legitimise a new mantra of austerity. This mantra is premised on the idea that the state can no longer afford the bloated welfare budget, that responsible government needs to “wean” people off benefits, and that sanctions imposed for not seeking work or for incorrectly filling in benefit claim forms serve to “encourage” people into work. Critics counter-argue that the punitive nature of sanctions has exacerbated deprivation and contributed to the growing use of food banks, a view the government disputes (Howarth; Caplan).Food Banks as Sites of Vulnerable CorporealityIn these shifting contexts, food banks have proliferated not only as sites of deprivation but also as sites of vulnerable corporeality, where people unable to draw on individual resources to respond to hunger congregate in search of social and material support. As growing numbers of people in Britain find themselves in this situation, the vulnerable corporeality of the hungry body becomes more pervasive and more visible. Hunger as a lived experience is laid bare in ever-longer food bank queues and also through the physiological, emotional and social consequences graphically described in personal blogs and in the testimonies of food bank users.Blogger Jack Monroe, for example, has recounted giving what little food she had to her child and going to bed hungry with a pot of ginger tea to “ease the stomach pains”; saying to her curious child “I’m not hungry,” while “the rumblings of my stomach call me a liar” (Monroe, Hunger Hurts). She has also written that her recourse to food banks started with the “terrifying and humiliating” admission that “you cannot afford to feed your child” and has expressed her reluctance to solicit the help of the food bank because “it feels like begging” (Monroe, Austerity Works?). Such blog accounts are corroborated in reports by food bank operators and a parliamentary enquiry which told stories of mothers not eating for days after being sanctioned under the benefit system; of children going to school hungry; of people leaving hospital after a major operation unable to feed themselves since their benefits have been cut; of the elderly having to make “hard choices” between “heat or eat” each winter; and of mixed feelings of relief and shame at receiving food bank parcels (All-Party Parliamentary Inquiry; Beattie; Cooper and Dumpleton; Caplan; Perry et al.). That is, two different visibilities have emerged: the shame of standing or being seen to stand in the food bank queue, and blogs that describe these feelings and the lived experience of hunger – both are vulnerable and visible, but in different ways and in different spaces: the physical or material, and the virtual.The response of doctors to the growing evidence of crisis was to warn that there were “all the signs of a public health emergency that could go unrecognised until it is too late to take preventative action,” that progress made against food poverty since the 1960s was being eroded (Ashton et al. 1631), and that the “robust last line of defence against hunger” provided by the welfare state was failing (Loopstra et al. n.p). Medical professionals thus sought to conscript the rhetorical resources of their professional credibility to highlight that this is a politically created public health crisis.This is not to suggest that acute hunger was absent for 50 years of the welfare state, but that with the closure of the last workhouses, the end of hunger marches, and the shutting of the soup kitchens by the 1950s, it became less visible. Over the past decade, hunger has become more visible in images of growing queues at food banks and stacked tins ready to be handed out by volunteers (Glaze; Gore) on production of a voucher provided on referral by professionals. Doctors, social workers or teachers are therefore tasked with discerning cases of need, deciding whose need is “genuine” and so worthy of food relief (see Downing et al.). The voucher system is regulated by professionals so that food banks are open only to those with a public identity constructed around bodily crisis. The sense of something as intimate as hunger being defined by others contrasts to making visible one’s own hunger through blogging. It suggests again how bodies become caught up in wider political struggles where not only is shame a co-construction of internal inadequacies and external judgements, but so too is hunger, albeit in different yet interweaving ways. New boundaries are being established between those who are deprived and those who are not, and also between those whose bodies are in short-term acute crisis, and those whose bodies are in long-term and chronic crisis, which is not deemed to be an emergency. It is in this context that food banks have also become sites of demarcation, shame, and contestation.Public debates about growing food bank queues highlight the ambiguous nature of societal responses to the vulnerability of hunger made visible. Government ministers have intensified internal shame in attributing growing food bank queues to individual inadequacies, failure to manage household budgets (Gove), and profligate spending on luxury (Johnston; Shipton). Civil society organisations have contested this account of hunger, turning shame away from the individual and onto the government. Austerity reforms have, they argue, “torn apart” the “basic safety net” of social responses to corporeal vulnerability put in place after the Second World War and intended to ensure that no-one was left hungry or destitute (Bingham), their vulnerability unattended to. Furthermore, the benefit sanctions impose punitive measures that leave families with “nothing” to live on for weeks. Hungry citizens, confronted with their own corporeal vulnerability and little choice but to seek relief from food banks, echo the Dickensian era of the workhouse (Cooper and Dumpleton) and indict the UK government response to poverty. Church leaders have called on the government to exercise “moral duty” and recognise the “acute moral imperative to act” to alleviate the suffering of the hungry body (Beattie; see also Bingham), and respond ethically to corporeal vulnerability with social policies that address unmet need for food. However, future cuts to welfare benefits mean the need for relief is likely to intensify.ConclusionThe aim of this paper was to explore the vulnerable corporeality of hunger through the lens of food banks, the twenty-first-century manifestations of charitable responses to acute need. Food banks have emerged in a gap between the renewal of a neo-liberal agenda of prudent government spending and the retreat of the welfare state, between struggles over resurgent ideas about individual responsibility and deep disquiet about wider social responsibilities. Food banks as sites of deprivation, in drawing attention to a newly vulnerable corporeality, potentially pose a threat to the moral credibility of the neo-liberal state. The threat is highlighted when the taboo of a hungry body, previously hidden because of shame, is being challenged by two new visibilities, that of food bank queues and the commentaries on blogs about the shame of having to queue for food.ReferencesAbbots, Emma-Jayne, and Anna Lavis. Eds. Why We Eat, How We Eat: Contemporary Encounters between Foods and Bodies. Farnham: Ashgate, 2013.All-Party Parliamentary Inquiry. “Feeding Britain.” 2014. 6 Jan. 2016 <https://foodpovertyinquiry.files.wordpress.com/2014/12/food>.Anderson, Patrick. “So Much Wasted:” Hunger, Performance, and the Morbidity of Resistance. Durham: Duke UP, 2010.Ashton, John R., John Middleton, and Tim Lang. “Open Letter to Prime Minister David Cameron on Food Poverty in the UK.” The Lancet 383.9929 (2014): 1631.Beattie, Jason. “27 Bishops Slam David Cameron’s Welfare Reforms as Creating a National Crisis in Unprecedented Attack.” Mirror 19 Feb. 2014. 6 Jan. 2016 <http://www.mirror.co.uk/news/uk-news/27-bishops-slam-david-camerons-3164033>.Bingham, John. “New Cardinal Vincent Nichols: Welfare Cuts ‘Frankly a Disgrace.’” Telegraph 14 Feb. 2014. 6 Jan. 2016 <http://www.telegraph.co.uk/news/religion/10639015/>.Butler, Judith. Frames of War: When Is Life Grievable? London: Verso, 2009.Cameron, David. “Why the Archbishop of Westminster Is Wrong about Welfare.” The Telegraph 18 Feb. 2014. 6 Jan. 2016 <http://www.telegraph.co.uk/news/politics/david-cameron/106464>.Caplan, Pat. “Big Society or Broken Society?” Anthropology Today 32.1 (2016): 5–9.Cavarero, Adriana. Horrorism: Naming Contemporary Violence. New York: Columbia UP, 2010.Chase, Elaine, and Robert Walker. “The Co-Construction of Shame in the Context of Poverty: Beyond a Threat to the Social Bond.” Sociology 47.4 (2013): 739–754.Clarke, John, Sharon Gewirtz, and Eugene McLaughlin (eds.). New Managerialism, New Welfare. London: Sage, 2000.Clarke, John, and Janet Newman. The Managerial State: Power, Politics and Ideology in the Remaking of Social Welfare. London: Sage, 1997.Cooper, Niall, and Sarah Dumpleton. “Walking the Breadline.” Church Action on Poverty/Oxfam May (2013): 1–20. 6 Jan. 2016 <http://policy-practice.oxfam.org.uk/publications/walking-the-breadline-the-scandal-of-food-poverty-in-21st-century-britain-292978>.Crossley, Nick. “The Politics of the Gaze: Between Foucault and Merleau-Ponty.” Human Studies 16.4 (1996): 399–419.Downing, Emma, Steven Kennedy, and Mike Fell. Food Banks and Food Poverty. London: House of Commons, 2014. 6 Jan. 2016 <http://www.parliament.uk/briefing-papers/SN06657/food-banks-and-food-poverty>.Field, Frank. “The Welfare State – Never Ending Reform.” BBC 3 Oct. 2011. 6 Jan. 2016 <http://www.bbc.co.uk/history/british/modern/field_01.shtml>.Foucault, Michel. Madness and Civilization: A History of Insanity in an Age of Reason. Trans. Richard Howard. New York: Random House, 1996.Glaze, Ben. “Tens of Thousands of Families Will Only Eat This Christmas Thanks to Food Banks.” The Mirror 23 Dec. 2015. 6 Jan. 2016 <http://www.mirror.co.uk/news/uk-news/tens-thousands-families-only-eat-705>.Gore, Alex. “Schools Teach Cookery on Fridays So Hungry Children from Families Too Poor to Eat Have Food for the Weekend.” The Daily Mail 28 Oct. 2012. 6 Jan. 2016. <http://www.dailymail.co.uk/news/article-2224304/Schools-teach-cookery-Friday>.Gove, Michael. “Education: Topical Questions.” Oral Answers to Questions 2 Sep. 2013.Hamilakis, Yannis. “Experience and Corporeality: Introduction.” Thinking through the Body: Archaeologies of Corporeality. Eds. Yannis Hamilakis, Mark Pluciennik, and Sarah Tarlow. New York: Kluwer Academic, 2002. 99-105.Howarth, Anita. “Hunger Hurts: The Politicization of an Austerity Food Blog.” International Journal of E-Politics 6.3 (2015): 13–26.Johnson, Mark. “Human Beings.” The Journal of Philosophy LXXXIV.2 (1987): 59–83.Johnston, Lucy. “Edwina Currie’s Cruel Jibe at the Poor.” Sunday Express Jan. 2014. 6 Jan. 2016 <http://www.express.co.uk/news/uk/454730/Edwina-Currie-s-cruel-jibe-at-poor>.Lambie-Mumford, Hannah, Daniel Crossley, and Eric Jensen. Household Food Security in the UK: A Review of Food Aid Final Report. February 2014. Food Ethics Council and the University of Warwick. 6 Jan. 2016 <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/283071/household-food-security-uk-140219.pdf>.Lambie-Mumford, Hannah, and Elizabeth Dowler. “Rising Use of ‘Food Aid’ in the United Kingdom.” British Food Journal 116 (2014): 1418–1425.Loopstra, Rachel, Aaron Reeves, David Taylor-Robinson, Ben Barr, Martin McKee, and David Stuckler. “Austerity, Sanctions, and the Rise of Food Banks in the UK.” BMJ 350 (2015).Lupton, Deborah. Food, the Body and the Self. London: Sage, 1996.Monroe, Jack. “Hunger Hurts.” A Girl Called Jack 30 July 2012. 6 Jan. 2016 <http://agirlcalledjack.com/2012/07/30/hunger-hurts/>.———. “Austerity Works? We Need to Keep Making Noise about Why It Doesn’t.” Guardian 10 Sep. 2013. 6 Jan. 2016 <http://www.theguardian.com/commentisfree/2013/sep/10/austerity-poverty-frugality-jack-monroe>.Perry, Jane, Martin Williams, Tom Sefton and Moussa Haddad. “Emergency Use Only: Understanding and Reducing the Use of Food Banks in the UK.” Child Poverty Action Group, The Church of England, Oxfam and The Trussell Trust. Nov. 2014. 6 Jan. 2016 <http://www.cpag.org.uk/sites/default/files/Foodbank Report_web.pdf>.Pickett, Brent. “Foucault and the Politics of Resistance.” Polity 28.4 (1996): 445–466.Powell, Martin. “New Labour and the Third Way in the British Welfare State: A New and Distinctive Approach?” Critical Social Policy 20.1 (2000): 39–60. Riches, Graham. “Food Banks and Food Security: Welfare Reform, Human Rights and Social Policy: Lessons from Canada?” Social Policy and Administration 36.6 (2002): 648–663.Sen, Amartya. “Poor, Relatively Speaking.” Oxford Economic Papers 35.2 (1983): 153–169. Shaw, Caroline. Britannia’s Embrace: Modern Humanitarianism and the Imperial Origins of Refugee Relief. Oxford: Oxford UP, 2015.Shipton, Martin. “Vale of Glamorgan MP Alun Cairns in Food Bank Row after Claims Drug Addicts Use Them.” Wales Online Sep. 2015. 6 Jan. 2016. <http://www.walesonline.co.uk/news/wales-news/vale-glamorgan-tory-mp-alun-6060730>. Vernon, James. Hunger: A Modern History. Cambridge, MA: Harvard UP, 2009.Walker, Robert, Sarah Purcell, and Ruth Jackson “Poverty in Global Perspective: Is Shame a Common Denominator?” Journal of Social Policy 42.02 (2013): 215–233.

IntroductionTransformation, claims McCracken, is the expression of consumer agency and individual freedom in which consumers, as “co-creators of culture,” are empowered to creatively construct new improved selves (xvi). No longer an “extraordinary event for extraordinary creatures,” transformation today is routine and accessible (McCracken xxi). Contemporary consumer culture encourages individuals to enact these transformations by turning to the market to purchase the resources they require to achieve their desired identity (Ellis et al. 179). This market model of transformation embraces the concept of the marketplace exchange where the one party satisfies the needs of the other in a mutually beneficial exchange relationship. For consumers, the market enables transformation through the purchase and consumption of the desired products and services which support identity building.Critics, however, argue that markets have less positive effects. While it is too simplistic to claim that markets manipulate consumers, marketing exchanges constitute an enduring shaping force on individuals and society (Laczniak and Murphy). Markets shape consumer identities by homogenising them and suppressing their self-expressive capabilities (Kozinets 22). As producers become more powerful, “the market is transformed from a consumer-driven mechanism to a sphere where the producers assimilate consumers’ needs to their own through commercial activity” (Sassatelli 76) (my italics). Marketing and promotion have a persuasive influence and their role in the transformation process is a crucial element in understanding the consumer’s impetus to transform. Consumer identity is of course neither fully a “liberatory act” nor “wholly dictated by the market” (Ellis et al. 182), but there is a relationship between consumer autonomy and the dictates of the market which can be explored through focusing on the transformation of identity through the consumption of cosmetic surgery. Cosmetic surgery is an important site of enquiry as a social practice which “merges the attention given to the body by an individual person with the values and priorities of the consumer society” (Martinez Lirola and Chovanec 490). The body, as Kathy Davis highlighted, has long been seen as a commodity which can be endlessly transformed (Davis, Reshaping the Female Body), and the market for cosmetic surgery is at the forefront of this commodification process (Aizura 305). What is new, however, is the increasing marketisation and commercialisation of the cosmetic surgery industry combined with rising consumerism in which surgical transformation can be purchased simply as a “lifestyle choice alongside fashion, fitness and therapy” (Elliott 7). In the cosmetic surgery market, “patients” are consumers. Rather than choosing cosmetic surgery in order to feel whole or normal, contemporary consumers see surgery as a grooming practice which is part of a body maintenance routine (Jones).As the cosmetic surgery market becomes progressively more competitive, it relies more and more on marketing and promotion for its survival. The intense rivalry between providers drives them, in some cases, to aggressive and often unethical promotional practices. In the related field of pharmaceuticals for example, marketers have been charged with explicitly manipulating social understanding of disease in order to increase profits (Brennan, Eagle, and Rice 17). Unlike TV make-over shows whose primary purpose is to entertain, or celebrity culture which influences indirectly through example, cosmetic surgery promotion sets out with intent to persuade consumers to choose surgical transformation. Cosmetic surgery is presented to consumers “through the neoliberal prism of choice,” encouraging women (mostly) to choose surgery as a self-improvement practice in order to “feel good or pamper herself” (Gurrieri, Brace-Govan, and Previte 534). In a promotional culture which valorises external values and ‘the new’ (Fatah 1), the cost, risk, and pain of surgery are downplayed as an increasing array of self-transformative possibilities are presented as consumption choices. This scenario sees the impetus to transform as driven as much by marketing imperatives as by consumers’ free choice. Indeed in mobilising the rhetoric of choice, the “autonomous” consumer, it seems, plays into the hands of the cosmetic surgery industry.This paper explores consumer transformation through cosmetic surgery by focusing on the tension between the rhetoric of consumer autonomy, freedom, and choice and that of the industry’s marketing and promotional practices in the United Kingdom (UK). I argue that while the consumer is an active player, expressing their freedom and agency in choosing self-transformation through surgery, that autonomy is influenced and constrained by the marketing and promotional practices of the industry. I focus on the inherent paradox in the discourse of transformation in consumer culture which advocates individual consumer freedom and creativity yet limits these freedoms to “acceptable” bodily forms constructed as the norm by promotional images of the cosmetic surgery industry. To paraphrase Susan Bordo, those promotions which espouse consumer choice and self-determination simultaneously eradicate individual difference and circumscribe choice (Unbearable Weight 250). Here I explore how ideals of autonomy, freedom, and choice are utilised to support consumer surgical transformation. Drawing on market research, professional publications, blogs and industry webpages used by UK consumers as they search for information, I demonstrate how marketing and promotion adopt these ideals to provide a visual reference and a language for consumer transformation, which has the effect of shaping and limiting consumer freedom and creativity. Consumer Transformation as Expression of Freedom Contemporary consumers need not be content just to admire the appearance of celebrities and film stars, but can actively engage in the creative construction of new improved selves through surgical transformation (McCracken). This transformation is often expressed by consumers as a liberatory act, as is illustrated by the women surveyed for a UK Department of Health report. As one respondent explains, “I think it’s just the fact that they can . . . and I think over the years, women have a battle with their bodies, as they change, different ages, they do, they struggle with trying to accept it over different years and the fact that you can, it’s like ‘wow, so what, it’s a bit of money, let’s just change ourselves’” (UK Department of Health 32). Even young consumers see cosmetic surgery as an easily available transformative option, such as this 16-year-old female research respondent who describes surgery as “Things that you don’t really need but you just feel you want to have them” (UK Department of Health 33). As these women attest, cosmetic surgery is seen as an increasingly normal and everyday practice. By rhetorically constructing the possibility of transformation as an expression of individual consumer empowerment (“wow, so what, it’s a bit of money, let’s just change ourselves”), they distance the practice “from negative associations with vanity” and oppression (Tait 131). This postmodern consumer is no dupe or victim but a “conscious subject who modifies their body as a project of identity” (Gibson 51) and for whom cosmetic surgery transformation is “the route to happiness and personal empowerment” (Tait 119). Surgical transformation is not a way to strive narcissistically after “an elusive beauty ideal” (Heyes 93). Instead, it is expressed as something they choose to do just for themselves—which Bordo calls the “for me” argument (“Braveheart, Babe, and the Contemporary Body”). In an increasingly visual culture, the accessibility and affordability of cosmetic surgery enable consumers, who are already accustomed to digitally editing their photographical images, to “edit” their physical bodies. This is candidly expressed by Singaporean blogger Ang Chiew Ting who writes, "When I learnt how to use Photoshop, the things that I edited about myself, those have now all been done in real life through plastic surgery. Whatever I wanted to change about my face, I have done." Yet, as I illustrate later, the emphasis on transformation as empowerment through exercising choice (“Whatever I wanted to change about my face, I have done"), plays into the hands of the industry as it “reproduces the logic of surgical industries” (Tait 121). In the politics of consumption, driven by neo-liberal ideologies, consumer choice is sovereign (Sassatelli 184), and it is in the ability to exercise choice, choosing surgery and taking responsibility for that choice, that agency and empowerment are expressed (Leve, Rubin, and Pusic). Blogger Stella Lee explains her decision as “I don't want to say I encourage plastic surgery, this is just my personal choice. It is like saying if I dye my hair purple then I want everyone to have purple hair too. It is simply just for me only. If you wish to do so, go ahead. If you're satisfied with what you have, go ahead.” This consumer is a “discerning and knowledgeable consumer” who researches information about potential surgical procedures and practitioners (Gimlin, “Imagining” 58) and embraces the ideology of self-determinism (Heyes). Consumers considering surgery may visit recommended doctors, research doctors online, and peruse beauty magazines (Leve, Rubin, and Pusic). Tatler magazine, for example, publishes an annual Beauty and Cosmetic Surgery Guide which celebrates “the newest, niftiest ways to reclaim your face and your figure” (Tatler nd). In taking responsibility for themselves, the contemporary consumer reflects the neoliberal agenda “that promotes empowerment through consumer choice and responsibility for self-care” (Leve, Rubin, and Pusic 131). Yet, consumer information on the suitability of surgery and alternative providers is often partial. As one research respondent recalled, “I just typed it into Google and then worked through whatever came up; you're trying to go for the names of companies that are a bit more reputable” (UK Department of Health 28). Internet searches most frequently identify promotional information from the surgery providers themselves including customer stories and testimonials, which seem informative in nature but which have persuasive intent to influence choice. Therefore although seemingly exerting agency by undertaking a process of search in order to make an informed choice, that choice is made within a promotional context that the consumer may not be fully aware exists.Consumer Transformation as Marketing ImperativeThe aim of marketing and promotion, as medicine meets consumerism, is to secure clients for cosmetic surgery (Mirivel). As a consequence, the discourse of cosmetic surgery is highly persuasive and commercially motivated, promoting the need for surgery by mobilising the existing ideological link between identity and physical appearance for commercial ends (Martinez Lirola and Chovanec 489). Promotional strategies include drawing attention to possible deficiencies in appearance, creating opportunities for surgery by problematising normal bodily states, promising intangible benefits, and normalising surgery by positioning it within a consumerist vision of success. Consumer transformation can be driven by perceived lack, inadequacy, or deficit, where a part of the body or face does not stand up to scrutiny when compared to media images. Marketing and promotion draw attention to this lack and imply that any deficiency in appearance can be remedied by consumption practices such as the purchase of hair dye, make-up, or, more drastically, cosmetic surgery. As one research respondent considering surgery explains, “I think people want to look their best and media portrays ‘perfect’ looking people or they portray a certain image and then because it’s what you see all the time, it almost feels like if you don't look like that, then it’s wrong” (UK Department of Health 18). The influence of media on the impetus to transform is explored elsewhere (see Wegenstein), so is not addressed further here. However, the insecurity which results from such media images is further exploited by the marketing and promotional strategies adopted by cosmetic surgery providers in an increasingly competitive marketplace. This does not go unnoticed by consumers: as one research respondent noted, “They pick out your insecurities as a tactic for making you purchase stuff . . . it was supposed to be a free consultation but they definitely do pressure you into having stuff” (UK Department of Health 19). In this deficiency model of transformation, the cosmetic surgery consumer is insecure, lacking in power and volition, and convinced of her inadequacy. This is exacerbated by the promotional images of models featured on cosmetic surgery websites against which consumers evaluate their own looks in a process of social comparisons (Markey and Markey 210). This reflects Bernadette Wegenstein’s notion of the cosmetic gaze, a circular process whereby “the act of looking at our bodies and those of others is informed by the techniques, expectations, and strategies of bodily modification” (2). In comparing themselves with the transformed images on surgery websites, consumers are drawn into a process of comparison that tells them how they should look. At the same time as convincing consumers of their inadequacies, providers also tell consumers that they are in control and can act autonomously to transform themselves. For example, a TV advert for The Hospital Group which shows three smiling “transformed” customers claims “If you’re unhappy with your appearance you could change it. If it affects your confidence you could overcome it. If it makes you feel self-conscious, you could take control with cosmetic surgery or dentistry from The Hospital Group” (my italics). In this way marketers marshal the neo-liberal rhetoric of consumer empowerment to encourage the consumption of cosmetic surgery and normalise the practice through the emphasis on choice. Marketing and promotional messages contribute further to these perceived deficits by problematising “normal” bodily conditions resulting from “normal” life experiences such as ageing and pregnancy. Surgeon Ran Rubinstein, for example, draws attention in his blog to thinning lips as an opportunity for lip augmentation: “Lip augmentation might seem like a trend among the younger crowd, but it’s something that people of any age can benefit from getting. As you get older, some areas of your body thin out while some thicken. You might find that you’re gaining weight around your stomach, while your lips and face are getting thin.” Problematising frames a real or perceived physical state as “as a medical problem that requires a medical solution,” subtly implying that cosmetic surgery is “an unavoidable necessity” which is medically justified (Martinez Lirola and Chovanec 503). For example, Jules’s testimonial for facial fillers frames natural, and even positive, features such as smile lines as problematic: “I smile a lot and noticed some smile lines coming through.” Indeed as medicine has historically defined the female body as “deficient and in need of repair,” cosmetic surgery can be legitimately proposed as a solution for “women’s problems with their appearance” (Davis, “A Dubious Equality” 55). Promotional messages emphasise the intrinsic benefits of external transformation, encouraging consumers to opt for surgery in order to align their external appearance with how they feel inside. Much of this discourse calls on consumers’ perceptions of a disparity between how they feel inside and their external body image (Gibson 54). For example, a testimonial from “Carole Anne 69” claims that facial fillers “make me feel like I’m the best version of myself.” (Note that Carole Anne, like all the women providing testimonials for this website, including Carol 50, Jules 38, or Pamela 59, is defined by her looks and by her age.) Although Gimlin’s research suggests that the notions of the “body reflecting the ‘true’ self or re-creating one’s ‘genuine’ appearance” have become less important (“Too Good” 930), they continue to dominate in customer testimonials on surgery websites. For example, Transform breast enlargement client Rebecca exclaims, “I’m still me, but it has completely transformed how I feel about myself on the inside, how I hold and present myself on the outside.” A typical promotional strategy is to emphasise the intangible benefits of cosmetic surgery, such as happiness or confidence. This is encapsulated in a 2011 print advert for Transform Cosmetic Surgery Group which shows a smiling young girl in a bikini holding a placard which reads, “I’ve just had my breasts done, but the biggest change you’ll see is on my face.” In promising happiness or self-confidence, intangible effects which are impossible to measure, marketers avoid the reality of surgery—where a cut is made, what is added or removed, how many stitches are required. Consumers know the world through shopping (Elliott 43), and marketers draw on this behaviour to associate surgery with any other purchase in the life of a successful consumer. Consumers are encouraged to choose from a gallery of looks, to “Browse through our Before and After Gallery for inspiration,” and the purchase is rendered more accessible through the use of discounts, offers, and incentives, which consumers are accustomed to seeing in familiar shopping contexts. Sales intent can be blatant, such as this appeal to disposable income on Realself.com: “Now that your 2015 taxes are (hopefully) filed and behind you, were you fortunate enough to get a refund? If it just so happens that the government will be returning some of your hard-earned cash, what will you be using it for? Electronic gadgets, an island vacation, a shopping spree . . . or plastic surgery?” Providers reduce perceived risk by implying that interventions such as facial fillers are considered normal practice for others, claiming that “Millions of women choose facial fillers, so that they can age exactly the way they want to” and by providing online interactive tools which consumers can use to manipulate facial features to see the potential effect of surgery (This-is-me.com).ConclusionThe aim of this article was to explore the tension between two different views of transformation, one which emphasised consumer autonomy, freedom, and market choice and the other which claims a more restrictive and manipulative influence of the market and its promotional practices. I argue that McCracken’s explanation of transformation as “the expression of consumer agency and individual freedom” (xvi) offers an overly optimistic view of consumer transformation. In the cosmetic surgery market, the expression of consumer autonomy and freedom rests on the discourse of choice. This same discourse is adopted by surgery providers in their persuasive strategies to secure new clients so that the market’s promotional language (e.g. a whole new you) becomes part of the consumer’s understanding of and articulation of cosmetic surgery transformation. I argue that marketing and promotion work to progress consumers along the path to surgery, by giving them reasons to do so. This is achieved by reflecting existing consumer anxieties as deficiencies, by creating new reasons for surgery by problematising normal conditions, by promising intangible benefits, and by normalising the purchase. These promotional practices also regulate and restrict consumers by presenting visual images of transformation which influence how others understand “the perfect you.” The gallery of looks on surgery websites constrains choice by signifying which looks are desirable, and “before and after” rhetoric emphasises the pivotal role of cosmetic surgery in achieving this transformation. ReferencesAizura, Aren. “Where Health and Beauty Meet: Femininity and Racialisation in Thai Cosmetic Surgery Clinics.” Asian Studies Review 33.3 (2009): 303–17.Bordo, Susan. “Braveheart, Babe, and the Contemporary Body.” 3 June 2016 <www.public.iastate.edu/~jwcwolf/Papers/Bordo>.———. Unbearable Weight: Feminism, Western Culture, and the Body. Berkeley: U of California P, 1993.Brennan, Ross, Lynn Eagle, and David Rice. “Medicalization and Marketing.” Journal of Macromarketing 30.1 (2010): 8–22.Davis, Kathy. “‘A Dubious Equality’: Men, Women and Cosmetic Surgery.” Body & Society 8.1 (2002): 49–65.———. Reshaping the Female Body. New York: Routledge, 1995.Elliott, Anthony. Making the Cut: How Cosmetic Surgery is Transforming our Lives. London: Reaktion Books, 2008.Ellis, Nick, James Fitchett, Matthew Higgins, Gavin Jack, Ming Lim, Michael Saren, and Mark Tadajewski. Marketing: A Critical Textbook. London: Sage, 2011. Fatah, Fazel. “Should All Advertising of Cosmetic Surgery Be Banned? Yes.” British Medical Journal 345 (7 Nov. 2012).Gibson, Margaret. “Bodies without Histories: Cosmetic Surgery and the Undoing of Time.” Australian Feminist Studies 21.41 (2006): 51–63.Gimlin, Debra. “‘Too Good to Be Real’: The Obviously Augmented Breast in Women’s Narratives of Cosmetic Surgery.” Gender & Society 27.6 (2013): 913–34.———. “Imagining the Other in Cosmetic Surgery.” Body & Society 16.4 (2010): 57–76.Gurrieri, Lauren, Jan Brace-Govan, and Josephine Previte. “Neoliberalism and Managed Health: Fallacies, Facades and Inadvertent Effects.” Journal of Macromarketing 34.4 (2014): 532–38.Heyes, Cressida. Self-Transformations: Foucault, Ethics, and Normalized Bodies. Oxford: Oxford UP, 2007.Jones, Meredith. “Clinics of Oblivion: Makeover Culture and Cosmetic Surgery Tourism.” PORTAL Journal of Multidisciplinary International Studies 8.2 (2011).Kozinets, Robert. “Can Consumers Escape the Market? Emancipatory Illuminations from Burning Man.” Journal of Consumer Research 29 (2002): 20–38. Laczniak, Eugene, and Patrick Murphy. “Normative Perspectives for Ethically and Socially Responsible Marketing.” Journal of Macromarketing 26 (2006): 154–77.Leve, Michelle, Lisa Rubin, and Andrea Pusic. “Cosmetic Surgery and Neoliberalisms: Managing Risk and Responsibility.” Feminism & Psychology 22. 1 (2011): 122–41.Markey, Charlotte, and Patrick Markey. “Emerging Adults’ Responses to a Media Presentation of Idealized Female Beauty: An Examination of Cosmetic Surgery in Reality Television.” Psychology of Popular Media Culture 1.4 (2012): 209–19.Martinez Lirola, Maria, and Jan Chovanec. “The Dream of a Perfect Body Come True: Multimodality in Cosmetic Surgery Advertising.” Discourse & Society 23.5 (2012): 487–507. McCracken, Grant. Transformations: Identity Construction in Contemporary Culture. Bloomington and Indianapolis: Indiana UP, 2008.Mirivel, Julien. “The Physical Examination in Cosmetic Surgery: Communication Strategies to Promote the Desirability of Surgery.” Health Communication 23.2 (2008): 153–70.Sassatelli, Roberta. Consumer Culture: History, Theory and Politics. London: Sage, 2007.Tait, Sue. “Television and the Domestication of Cosmetic Surgery.” Feminist Media Studies 7.2 (2007): 119–35. Tatler Magazine. “Beauty & Cosmetic Surgery Guide 2016.” Tatler 2016. 3 June 2016 <http://www.tatler.com/guides/beauty--cosmetic-surgery-guide/2016>.UK Department of Health Research. “Regulation of Cosmetic Interventions: Research among the General Public and Practitioners.” 28 Mar. 2013. Version 3. 22 Apr. 2016 <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192029/Regulation_of_Cosmetic_Interventions_Research_Report.pdf>.Wegenstein, Bernadette. The Cosmetic Gaze: Body Modification and the Construction of Beauty. Cambridge, Massachusetts: MIT Press, 2012.

Historically, science and medicine have been a great source of inspiration for fiction writers. Mary Shelley, in the 1831 introduction to her novel Frankenstein said she was been inspired, in part, by discussions about scientific experiments, including those of Darwin and Galvani. Shelley states “perhaps a corpse would be re-animated; galvanism had given token of such things: perhaps the component parts of a creature might be manufactured, brought together, and endued with vital warmth” (10). Countless other authors have followed her lead, from H.G. Wells, whose mad scientist Dr Moreau takes a lead from Shelley’s Dr Frankenstein, through to popular contemporary writers of adult fiction, such as Michael Crichton and Kathy Reichs, who have drawn on their scientific and medical backgrounds for their fictional works. Science and medicine themed fiction has also proven popular for younger readers, particularly in dystopian settings. Reichs has extended her writing to include the young adult market with Virals, which combines forensic science with the supernatural. Alison Allen-Grey’s 2009 novel, Lifegame, deals with cloning and organ replacement. Nathan Hobby’s The Fur is based around an environmental disaster where an invasive fungal-fur grows everywhere, including in people’s internal organs. Catherine Jinks’ Piggy in the Middle incorporates genetics and biomedical research into its horror-science fiction plot. Brian Caswell’s young adult novel, Cage of Butterflies uses elements of neuroscience as a plot device. However, although Caswell’s novel found commercial and critical success—it was shortlisted in the 1993 Children’s Book Council of Australia (CBCA) Book of the Year Awards Older Readers and was reprinted several times—neuroscience is a field that writers of young adult fiction tend to either ignore or only refer to on the periphery. This paper will explore how neuroscientific and dystopian elements interact in young adult fiction, focusing on the current trend for neuroscientific elements to be something that adolescent characters are subjected to rather than something they can use as a tool of positive change. It will argue that the time is right for a shift in young adult fiction away from a dystopian world view to one where the teenaged characters can become powerful agents of change. The term “neuroscience” was first coined in the 1960s as a way to hybridise a range of disciplines and sub-disciplines including biophsyics, biology and chemistry (Abi-Rached and Rose). Since then, neuroscience as a field has made huge leaps, particularly in the past two decades with discoveries about the development and growth of the adolescent brain; the dismissal of the nature versus nurture dichotomy; and the acceptance of brain plasticity. Although individual scientists had made discoveries relating to brain plasticity in adult humans as far back as the 1960s, for example, it is less than 10 years since neuroplasticity—the notion that nerve cells in human brains and nervous systems are malleable, and so can be changed or modified by input from the environment—was accepted into mainstream scientific thinking (Doidge). This was a significant change in brain science from the once dominant principle of localisation, which posited that specific brain functions were fixed in a specific area of the brain, and that once damaged, the function associated with a brain area could not improve or recover (Burrell; Kolb and Whishaw; Doidge). Furthermore, up until the late 1990s when neuroscientist Jay Giedd’s studies of adolescent brains showed that the brain’s grey matter, which thickens during childhood, thins during adolescence while the white matter thickens, it was widely accepted the human brain stopped maturing at around the age of twelve (Wallis and Dell). The research of Giedd and others showed that massive changes, including those affecting decision-making abilities, impulse control and skill development, take place in the developing adolescent brain (Carr-Gregg). Thus, within the last fifteen years, two significant discoveries within neuroscience—brain plasticity and the maturation of the adolescent brain­—have had a major impact on the way the brain is viewed and studied. Brian Caswell’s Cage of Butterflies, was published too early to take advantage of these neuroscientific discoveries. Nevertheless the novel includes some specific details about how the brains of a group of children within the story, the Babies, have been altered by febrile convulsions to create an abnormality in their brain anatomy. The abnormality is discovered by a CAT scan (the novel predates the use of fMRI brain scans). Due to their abnormal brain anatomy, the Babies are unable to communicate verbally but can communicate telepathically as a “shared mind” with others outside their small group. It is unlikely Caswell would have been aware of brain plasticity in the early 1990s, nevertheless, in the narrative, older teens are able to slowly understand the Babies by focusing on their telepathic messages until, over time, they can understand them without too much difficulty. Thus Caswell has incorporated neuroscientific elements throughout the plot of his novel and provided some neuroscientific explanation for how the Babies communicate. In recent years, several young adult novels, both speculative and contemporary, have used elements of neuroscience in their narratives; however, these novels tend to put neuroscience on the periphery. Rather than embracing neuroscience as a tool adolescent characters can use for their benefit, as Caswell did, neuroscience is typically something that exists around or is done to the characters; it is an element over which they have no control. These novels are found across several sub-genres of young adult fiction, including science fiction, speculative fiction and contemporary fiction. Most place their narratives in a dystopian world view. The dystopian settings reinforce the idea that the world is a dangerous place to live, and the teenaged characters living in the world of the novels are at the mercy of powerful oppressors. This creates tension within the narrative as the adolescents battle authorities for power. Without the ability to use neuroscientific advantages for their own gain, however, the characters’ power to change their worlds remains in the hands of adult authorities and the teenaged characters ultimately lose the fight to change their world. This lack of agency is evident in several dystopian young adult novels published in recent years, including the Uglies series and to a lesser extent Brain Jack and Dark Angel. Scott Westerfeld’s Uglies series is set in a dystopian future world and uses neuroscientific concepts to both reinforce the power of the ruling regime and give limited agency to the protagonists. In the first book in the series, Uglies, the science supports the narrative where necessary but is always subservient to the action. Westerfeld’s intended the Uglies series to focus on action. Westerfield states “I love a good action sequence, and this series is of full of hoverboard chases, escapes through ancient ruins, and leaps off tall buildings in bungee jackets” (Books). Nevertheless, the brain’s ability to rewire itself—the neuroscientific concept of brain plasticity—is a central idea within the Uglies series. In book one, the protagonist Tally Youngblood is desperate to turn 16 so she can join her friends and become a Pretty. However, she discovers the operation to become a Pretty involves not just plastic surgery to alter her looks: a lesion is inflicted on the brain, giving each Pretty the equivalent of a frontal lobotomy. In the next book, Pretties, Tally has undergone the procedure and then becomes one of the elite Specials, and in the third instalment she eventually rejects her Special status and returns to her true nature. This latter process, one of the characters explains, is possible because Tally has learnt to rewire her brain, and so undo the Pretty operation and the procedure that made her a Special. Thus neuroscientific concepts of brain injury and recovery through brain plasticity are prime plot devices. But the narrative offers no explanations for how Tally and some others have the ability to rewire their brains to undo the Pretty operation while most do not. The apparent complexity of the neuroscience is used as a surface plot device rather than as an element that could be explored to add narrative depth. In contrast, the philosophical implications of recent neuroscientific discoveries, rather than the physical, are explored in another recent young adult novel, Dark Angel. David Klass’ novel, Dark Angel, places recent developments in neuroscience in a contemporary setting to explore the nature of good and evil. It tells the story of 17-year-old Jeff, whose ordinary, small-town life implodes when his older brother, Troy, comes home on parole after serving five years for manslaughter. A school assignment forces Jeff to confront Troy’s complex nature. The science teacher asks his class “where does our growing knowledge of the chemical nature of the brain leave us in terms of... the human soul? When we think, are we really making choices or just following chemical pathways?” (Klass 74). This passage introduces a neuroscientific angle into the plot, and may refer to a case brought before the US Supreme Court in 2005 where the court admitted a brief based on brain scans showing that adolescent brains work differently than adult brains (Madrigal). The protagonist, Jeff, explores the nature of good and evil through this neuroscientific framework as the story's action unfolds, and examines his relationship with Troy, who is described in all his creepiness and vulnerability. Again through the teacher, Klass incorporates trauma and its impact on the brain from a neuroscientific perspective: There are psychiatrists and neurologists doing studies on violent lawbreakers...who are finding that these felons share amazingly similar patterns of abusive childhoods, brain injuries, and psychotic symptoms. (Klass 115)Jeff's story is infused with the fallout of his brother’s violent past and present, yet there is no hint of any trauma in Jeff’s or Troy’s childhoods that could be seen as a cause for Troy’s aberrant behaviour. Thus, although Klass’ novel explores more philosophical aspects of neuroscience, like Westerfeld’s novel, it uses developments in neuroscience as a point of interest. The neuroscience in Dark Angel is not embedded in the story but is a lens through which to view the theme of whether people are born evil or made evil. Brain Jack and Being are another two recent young adult novels that explore physical and philosophical aspects of modern neuroscience to some extent. Technology and its possible neurological effects on the brain, particularly the adolescent brain, is a field of research popularised by English neuroscientist Baroness Susan Greenfield. Brian Falkner’s 2010 release, Brain Jack, explores this branch of neuroscience with its cautionary tale of a hands-free device—a cap with small wires that attach to your head called the neuro-headset­—that allows you to control your computer with your thoughts. As more and more people use the neuro-headset, the avatar designed to help people learn to use the software develops consciousness and its own moral code, destroying anyone who it considers a threat by frying their brains. Like Dark Angel and Uglies, Brain Jack keeps the neuroscience on the periphery as an element over which the characters have little or no control, and details about how the neuro-headset affects the brain of its wearers, and how the avatar develops consciousness, are not explored. Conversely, Kevin Brooks’ novel Being explores the nature of consciousness outside the field of neuroscience. The protagonist, Robert, goes into hospital for a routine procedure and discovers that instead of internal organs, he has some kind of hardware. On the run from authorities who are after him for reasons he does not understand, Robert tries frantically to reconstruct his earliest memories to give him some clue as to who, or what, he really is: if he does not have normal human body parts, is he human? However, whether or not he has a human brain, and the implications of either answer for his consciousness, is never addressed. Thus, although the novels discussed above each incorporate neuroscience to some degree, they do so at a cursory level. In the case of Being this is understandable as neuroscience is never explicitly mentioned; rather it is a possible sub-text implied through the theme of consciousness. In Dark Angel, through the teacher as mouthpiece, neuroscience is offered up as a possible explanation for criminal behaviour, which causes the protagonist to question his beliefs and judgements about his brother. However, in Uglies, and to a lesser extent in Brain Jack, neuroscience is glossed over when more detail may have added extra depth and complexity to the novels. Fast-paced action is a common element in much contemporary young adult fiction, and thus it is possible that Westerfeld and Falkner both chose to sacrifice complexity for the sake of action. In Uglies, it is likely this is the case, given Westerfeld’s love of action sequences and his attention to detail about objects created exclusively for his futuristic world. However, Brain Jack goes into explicit detail about computer hacking. Falkner’s dismissal of the neuroscientific aspects of his plot, which could have added extra interest, most likely stems from his passion for computer science (he studied computer science at university) rather than a distaste for or ignorance of neuroscience. Nevertheless Falkner, Westerfeld, Brooks, and to a lesser extent Klass, have each glossed over a source of potential power that could turn the dystopian worlds of their novels into one where the teenaged protagonists hold the power to make lasting change. In each of these novels, neuroscientific concepts are generally used to support a bleak or dystopian world view. In Uglies, the characters have two choices: a life as a lobotomised Pretty or a life on the run from the authorities, where discovery and capture is a constant threat. The USA represented in Brain Jack descends into civil war, where those unknowingly enslaved by the avatar’s consciousness fight against those who refuse to wear the neuro-headsets. The protagonist in Being lives in hiding from the secret authorities who seek to capture and destroy him. Even in Dark Angel, the neuroscience is not a source of comfort or support for the protagonist, whose life, and that of his family, falls apart as a consequence of his older brother’s criminal actions. It is only in the 1990s novel, Cage of Butterflies, that characters use a neuroscientific advantage to improve their situation. The Babies in Caswell’s Cage of Butterflies are initially victims of their brain abnormality; however, with the help of the teenaged characters, along with two adult characters, they are able to use their “condition” to help create a new life for themselves. Telepathically communicating through their “shared mind,” the Babies coordinate their efforts with the others to escape from the research scientists who threaten their survival. In this way, what starts as a neurological disability is turned into an advantage. Cage of Butterflies illustrates how a young adult novel can incorporate neuroscience into its narrative in a way that offers the young adults agency to make positive changes in their lives. Furthermore, with recent neuroscientific discoveries showing that adolescence is a vital time for brain development and growth, there is potential for neuroscience to be explored as an agent of positive change in a new wave of young adult fiction, one that adopts a non-dystopian (if not optimistic) world view. Dystopian young adult fiction has been enjoying enormous popularity in western publishing in the past few years with series such as Chaos Walking, Hunger Games and Maze Runner trilogies topping bestseller lists. Dystopian fiction’s appeal to young adult audiences, states Westerfeld, is because: Teenagers’ lives are constantly defined by rules, and in response they construct their identities through necessary confrontations with authority, large and small. Imagining a world in which those authorities must be destroyed by any means necessary is one way of expanding that game. ("Teenage Wastelands")Teenagers often find themselves in trouble, and are almost as often like to cause trouble. Placing them in a fictional dystopian world gives them room to fight authority; too often, however, the young adult protagonists are never able to completely escape the world the adults impose upon them. For example, the epilogue of James Dashner’s The Maze Runner tells the reader the surviving group have not escaped the makers of the maze, and their apparent rescuers are part of the same group of adult authorities. Caswell’s neurologically evolved Babies, along with their high IQ teenage counterparts, however, provide a model for how young protagonists can take advantage of neuroscientific discoveries to cause trouble for hostile authorities in their fictional worlds. The power of the brain harnessed by adolescents, alongside their hormonal changes, is by its nature a recipe for trouble: it has the potential to give young people an agency and power adults may fear. In the everyday, lived world, neuroscientific tools are always in the hands of adults; however, there needs to be no such constraint in a fictional world. The superior ability of adolescents to grow the white matter of their brains, for example, could give rise to a range of fictional scenarios where the adolescents could use their brain power to brainwash adults in authority. A teenage neurosurgeon might not work well in a contemporary setting but could be credible in a speculative fiction setting. The number of possible scenarios is endless. More importantly, however, it offers a relatively unexplored avenue for teenaged characters to have agency and power in their fictional worlds. Westerfeld may be right in his assertion that the current popularity of dystopian fiction for young adults is a reaction to the highly monitored and controlled world in which they live ("Teenage Wastelands"). However, an alternative world view, one where the adolescents take control and defeat the adults, is just as valid. Such a scenario has been explored in Cory Doctorow’s For the Win, where marginalised and exploited gamers from Singapore and China band together with an American to form a global union and defeat their oppressors. Doctorow uses online gaming skills, a field of expertise where youth are considered superior to adults, to give his characters power over adults in their world. Similarly, the amazing changes that take place in the adolescent brain are a natural advantage that teenaged characters could utilise, particularly in speculative fiction, to gain power over adults. To imbue adolescent characters with such power has the potential to move young adult fiction beyond the confines of the dystopian novel and open new narrative pathways. The 2011 Bologna Children’s Book Fair supports the view that western-based publishing companies will be looking for more dystopian young adult fiction for the next year or two (Roback). However, within a few years, it is possible that the popularity of zombies, werewolves and vampires—and their dominance of fictional dystopian worlds—will pass or, at least change in their representations. The “next big thing” in young adult fiction could be neuroscience. Moreover, neuroscientific concepts could be incorporated into the standard zombie/vampire/werewolf trope to create yet another hybrid to explore: a zombie virus that mutates to give a new breed of undead creature superior intelligence, for example; or a new cross-breed of werewolf that gives humans the advantages of the canine brain with none of the disadvantages. The capacity and complexity of the human brain is enormous, and thus it offers enormous potential to create exciting young adult fiction that explores new territory, giving the teenaged reader a sense of their own power and natural advantages. In turn, this is bound to give them infinite potential to create fictional trouble. References Abi-Rachedm, Rose. “The Birth of the Neuromolecular Gaze.” History of the Human Sciences 23 (2010): 11-36. Allen-Gray, Alison. Lifegame. Oxford: Oxford UP, 2009. Brooks, Kevin. Being. London: Puffin Books, 2007. Burrell, Brian. Postcards from the Brain Museum. New York: Broadway, 2004. Carr-Gregg, Michael. The Princess Bitchface Syndrome. Melbourne: Penguin Books. 2006. Caswell, Brian. A Cage of Butterflies. Brisbane: University of Queensland Press, 1992. Dashner, James. The Maze Runner. Somerset, United Kingdom: Chicken House, 2010. Doctorow, Cory. For the Win. New York: Tor, 2010. Doidge, Norman. The Brain That Changes Itself. Melbourne: Scribe, 2007. Falkner, Brian. Brain Jack. New York: Random House, 2009. Hobby, Nathan. The Fur. Fremantle: Fremantle Press, 2004. Jinks, Catherine. Piggy in the Middle. Melbourne: Penguin, 1998. Klass, David. Dark Angel. New York: HarperTeen, 2007. Kolb, Bryan, and Ian Whishaw. Fundamentals of Human Neuropscychology, New York, Worth, 2009. Lehrer, Jonah. “The Human Brain Gets a New Map.” The Frontal Cortex. 2011. 10 April 2011 ‹http://www.wired.com/wiredscience/2011/04/the-human-brain-atlas/›. Madrigal, Alexis. “Courtroom First: Brain Scan Used in Murder Sentencing.” Wired. 2009. 16 April 2011 ‹http://www.wired.com/wiredscience/2009/11/brain-scan-murder-sentencing/›. Reichs, Kathy. Virals. London: Young Corgi, 2010. Roback, Diane. “Bologna 2011: Back to Business at a Buoyant Fair.” Publishers Weekly. 2011. 17 April 2011 ‹http://www.publishersweekly.com/pw/by-topic/childrens/childrens-industry-news/article/46698-bologna-2011-back-to-business-at-a-buoyant-fair.html›. Shelley, Mary. Frankenstein. London: Arrow Books, 1973. Wallis, Claudia, and Krystina Dell. “What Makes Teens Tick?” Death Penalty Information Centre. 2004. 10 April 2011 ‹http://www.deathpenaltyinfo.org/what-makes-teens-tick-flood-hormones-sure-also-host-structural-changes-brain-can-those-explain-behav›. Wells, H.G. The Island of Dr Moreau. Melbourne: Penguin, 1896. Westerfeld, Scott. Uglies. New York: Simon Pulse, 2005. ———. Pretties. New York: Simon Pulse, 2005. ———. Specials. New York: Simon Pulse, 2006. ———. Books. 2008. 1 Sep. 2010 ‹http://www.scottwesterfeld.com/author/books.htm›. ———. “Teenage Wastelands: How Dystopian YA Became Publishing’s Next Big Thing.” Tor.com 2011. 17 April 2011 ‹http://www.tor.com/blogs/2011/04/teenage-wastelands-how-dystopian-ya-became-publishings-next-big-thing›.

Tiffany is running down a suburban street with headphones and a hoodie on. Her breath is clearly audible, rhythmic, steady, and in pace with her footsteps. The Tiffany’s Story video testimonial on the Be Smart. Be Well. website then cuts to Tiffany sitting at home describing her earlier experiences with asthma: “The hospital became like my second home... I couldn’t breathe on my own.” Dr. Wolf, who has been treating Tiffany since she was diagnosed with asthma at age 8, joins in, “At that time she had really severe asthma. It was very difficult to manage and remained very difficult to manage for many years” (Be Smart. Be Well). As a child, Tiffany could never run, with steady breath, as she did at the beginning of the video, titled The Right Meds Keep Her in the Ring (Be Smart. Be Well). But after figuring out a treatment regime that worked, Tiffany became a healthy teenager; the video features her in contexts where she is jogging, smiling radiantly with her mother, and holding up victory belts from her boxing matches. From a child unable to breathe on her own, to a teenager with dreams of going to the Olympics, Tiffany’s asthma story underscores some of the defining narratives of contemporary asthma care. Her experience moves from uncontrolled asthma that limited her activities to a well-managed condition where she is able to pursue her aspirations without interference. Her Olympic dreams fit perfectly, reproduce even, the iconic image of the asthmatic athlete. It’s an image that has been in circulation since the early years of the contemporary asthma epidemic, a moment in the 1990s when federal health agencies and advocacy organizations worked to give the growing population of child asthmatics hope and encouragement to overcome their asthma. Yet the figure of the athletic asthmatic, and other accomplished icons with well-controlled asthma, also promotes an idealized image of health: “you can be greater than you are,” when you take your medication. The messages, of course, are well intentioned, designed to educate and show kids that asthma does not equate with disability. Yet these messages frequently work on logic where drugs control symptoms to enable you to do better in life. In some corners of asthma care, concern with symptoms is subsumed by narratives of activity and accomplishment. This article sketches shifts in the meaning of health and disease in the context of asthma treatment, moving from a time when treatments were not disease-specific and illness was seen as debilitating, to the contemporary moment where pharmaceutical companies market disease and promote health through direct-to-consumer advertising (DTCA). It’s a move situated within a broader, biomedicalized context where health isn’t just achieved, it’s augmented. Tiffany’s story is typical of someone with severe or even moderate asthma: uncontrolled symptoms, use of emergency care, unresponsive to medications, and an inability to live life as fully as desired. Symptoms and the threat of symptoms prevent people from undertaking routine activities (such as exercise, visiting friends, or attending work or school) and going into spaces that might trigger an attack. Asthma, in other words, can prevent people from living a “normal” life. But it can also be more than a chronic inconvenience that shapes behaviors; in the U.S., asthma still kills more than 3,000 people each year (Moorman et al. 20). Medical practitioners, researchers, and patients persistently search for insight into asthma’s causes and possible cures (Whitmarsh). Both cause and cure still allude, but preventative measures have improved dramatically in the last thirty years, through both pharmaceutical advancements and better public health approaches. Whereas a century ago, or even 30 years ago, severe asthmatics would have lead quite restricted lives—confined to their homes and unable to be active—today’s asthmatics are not limited by their condition to the degree they were decades before. We see this in asthma research that shows improved morbidity, decreased hospitalizations, and better quality of life (Moorman et al. 1-67). We also see this in DTCA, asthma advocacy campaigns, and even public health messages that actively combat the historic image of the weak, invalid asthmatic with stories of famous athletes, entertainers, or politicians who overcame asthma to achieve great things. It moves the discourse from an overly negative image—as one asthmatic interlocutor conveyed, “there was a stereotype in the 80s, in the movies, where the nerdy wimpy kid always had asthma, and the inhaler was associated with that”—to an extraordinarily positive image of high achieving asthmatics. Inhalers, formerly a sign of weakness, are now common in competitive sport contexts (Arie 344). The contrast between these representations—the 1980s nerdy wimp and the 21st century athlete—is stark. The latter image participates in the shift towards augmented health, where active bodies have become the new idealized norm. The shifting representations of asthmatics, even over the last twenty years, makes sense in the context of biomedicalization (Clarke et al. 172), where treatment regimes moved from a focus on “attaining control over the body” under medicalization, to “enabling the transformation of bodies to include desired new properties and identities” (Clarke et al. 183). The right treatment will allow you to do things that your body wouldn’t let you do otherwise. The question is: should treatment be sold on this premise? What would have been considered a return to health a hundred years ago wouldn’t be considered doing enough to manage your asthma today. A hundred years ago, the absence of symptoms would have been a success; today, the focus is on the degree to which one feels limited and how much you can accomplish in the span of 24-hours. Missed school and work days are a key measure in asthma epidemiology and care; these public health measures not only signal uncontrolled asthma, but do so by counting absence in the context of labor. The discursive shift can also be seen in the change from the urge to “breathe easy” (language from the Centers for Disease Control) to suggestions in pharmaceutical ads that you can “breathe better.” What new selves are being created by emergent health rhetorics, as Metzel asks (6), rhetorics which seem to be consumerist and neoliberal as much as they are biomedical? Role Reversal Historically, those with severe asthma led their lives carefully, or in reclusion. French novelist Marcel Proust, in addition to his literary accomplishments, spent much of his life confined to his home. Despite searching through medical texts and experimenting with various treatments, Proust’s asthma “dominated” his daily life, in the words of Mark Jackson (6). Writing of asthma’s history, Jackson continues, Proust constitutes the archetypal asthmatic, whose breathlessness and discomfort echo across space and time. Proust’s intimate descriptions of his symptoms—‘an asthmatic never knows if he will be able to breathe’ he wrote to the novelist Andre Gide in 1919—bear striking similarities both to Greek and medieval accounts of asthma many centuries earlier and to recent surveys suggesting that, at the turn of the millennium, many asthmatics continue to suffer from severe attacks that prevent them from speaking or make them fear for their lives. (8) In Proust’s time, advertisements for asthma and other respiratory treatments focused on providing symptom relief; some even purported to cure respiratory woes. These advertisements were rarely asthma specific, in part, because manufacturers sought the widest possible customer base, but also because it was difficult to distinguish one respiratory illness from another (Jackson 201). Asthmatics like Proust tried a range of remedies, including asthma cigarettes, the Carbolic Smoke Ball, and various forms of early inhalers. Most of these early asthma remedies instructed customers to use their product when in need of relief. Some ads stated that more regular use could stave off symptoms as well remedy them in the moment, but prevention wasn’t the primary message. The principle focus was addressing symptoms at hand. Just about a hundred years later, at the beginning of the U.S. asthma epidemic, symptoms were still center stage. National attention turned towards the asthmatic condition as the public health effects of severe asthma became visible—asthma-related deaths and hospitalizations had increased, along with rising prevalence rates. Asthma—formerly kept hidden in homes and in low-income communities—emerged as a major public health issue (Mitman 245). Advocacy campaigns were created on the heels of the epidemic’s emergence; they aimed to make asthma visible and show kids that their condition didn’t have to get in the way of life. Elite athletes became central figures in these campaigns. The Asthma All-Stars program, which featured Olympic medalists Jackie Joyner-Kersee and Amy Van Dyken, as well as Pittsburgh Steeler Jerome Bettis, worked to educate the public through acknowledgement of the condition as well as treatment advocacy. The National Library of Medicine’s exhibit on asthma, “Breath of Life” (1999), exemplifies this period with a showcase of famous asthmatics. In the exhibit, more than half the profiles of contemporary asthmatics feature Olympic or all-star athletes; entertainers, politicians, and scientists round out the exhibit. The legacy of the asthmatic athlete persists today; it’s still common to see sports figures speaking at fundraisers or spearheading events. These images are important, particularly for patient populations who truly feel limited and unable to do things because of their asthma. Athletes who speak about their condition are always clear: well-controlled asthma comes from adherence to treatment. The importance of these images also stems from the use of the image of the All-Star asthmatic to counter the historical stereotype of the weak, invalid asthmatic, who, like Proust, could not even leave the house. The man who recalled the stereotyped asthmatic from the 1980s, stated “I think I mapped myself onto that [stereotype], like, this is a disability, right, the media tells me this is a disability cause it’s always the kids who can’t do anything who are puffing their puffers.” In step with emergent 21st century health rhetoric, and increasing asthma prevalence, the image of the asthmatic was revised, falling in line with newly normalized health ideals (Clarke et al. 181; Metzel 2; Sinding 262). Active Asthmatics If 19th and early 20th century inhaler advertisements declared their products could relieve if not cure respiratory symptoms, at the beginning of the 21st century asthma treatment went beyond simply relieving symptoms; advertisements and medical discourse emphasized preventative symptom control, improved lung function, and better breathing. With the development of long-term controller medications, many asthmatics could reliably prevent symptoms a majority of the time. When combination inhalers hit the market in the early 2000s, the mood of advertisements could be summed up by a line from a GlaxoSmithKline commercial, “Coping is not the same as controlling” (GlaxoSmithKline). Prevention rather than symptom relief was the order of the new century. And yet just in the last ten years, pharmaceutical messages have shifted yet again, moving from an emphasis on controlling symptoms to living a better life: don’t let asthma slow you down, or stop you from living the life you want to live. It’s a message predicated on a particular view of what a normal life should look like, one characterized as augmented health. A 2012 Advair commercial reflects the tone of augmented health, “Asthma can hold you back, but it doesn’t always have to. Advair is clinically proven to significantly increase symptom free days, to help you do more of the things you like to do, more of the things you have to do, and more of what you want to do” (Advair). Strategically placed throughout the commercial, a voice chimes in “GO!” as the hero of the commercial, a middle aged asthmatic man, bikes down a wooded trail; moves through a busy hallway where he greets one person after the next, all of whom hand him file folders or blue prints; dances at a nightclub; and walks down bleachers to join a group of friends at a ballgame. The commercial ends with the man arriving home well after dark, comfortably settling into bed, and then energetically waking up to do it all over again the next day. Marked by words like increase, more, and go, the Advair commercial depicts a life full of activity. Not only that, the commercial leverages contexts that are commonly problematic for asthmatics: being outside and in foliage rich areas; biking and dancing, or other physical activities that could leave one breathless; and sleeping comfortably—nighttime attacks are common among asthmatics. The message is clear: look at all the things asthmatics can do when their condition is well controlled—with Advair, of course. It’s a message that builds on an earlier trend in asthma advocacy, during the 1990s, when well-known asthmatic athletes were used to bring visibility to asthma. If asthma control in the 1990s emphasized that asthmatics didn’t need to be held back, 21st century ads suggest that one could do more. By augmenting your health, asthma control can transform your life by allowing you to do more.Today, DTCA for asthma drugs are just as likely to emphasize improved lung function as they are symptom control, and, as advertised in the Advair commercial, improved lung function enables one to do more. A man featured in a 2012 Symbicort commercial explains, “Symbicort helps significantly improve my lung function, starting within five minutes… With Symbicort, today I’m breathing better” (Symbicort). The man’s renewed capacity to go on fishing trips with loved ones is the example in this commercial. Control, relief, and cure are nowhere to be found in these DTC advertisements; symptoms have been dropped from the frame. Rather than work off illness, or the older stereotype of the weak, homebound asthmatic, the new wave of DTCA champions augmented health: a higher quality of life, where patient-consumers can “do” whatever they like. What would have been considered a return to normal a hundred years ago, in Proust’s time, wouldn’t be considered doing enough to manage your asthma today. A hundred years ago, getting out of the house would have been enough; today, it’s a question of how much can you accomplish in the span of 24-hours. The portrayal of health in these DTCA calls to mind Lauren Berlant’s description of OTC cold medicine, which claim to make you feel better, but are really more concerned with making sure people can stay productive (28). Conclusion Had Proust lived a century later, he may have, like Tiffany, led a less restricted life. Or as Dr. Wolf put it, “A normal life. Busy and as active as she’d like to be. But she needs to take medication to do it” (Be Well. Be Smart). Symptom-free doesn’t seem to be enough anymore. Contemporary images of asthmatics—as an all-star athlete, an aspiring boxer, and a hyper-busy city dweller—are shaped by an imagined healthy norm. Advocacy campaigns originally intended to combat long-standing negative representations partake in the promotion of augmented health. Increasingly, health is no longer defined by the absence of symptoms, but by how active you are and how much you do. Busy and productive is a gold standard of the idealized norm, a norm that circulates—to a greater or lesser extent—in direct-to-consumer advertising, asthma advocacy campaigns, and public health messages (Sinding 262). Without doubt, the pharmaceutical industry plays a tremendous role in shaping contemporary health norms. Yet, as Joseph Dumit describes it, "the pharmaceutical industry is a massive elephant. Like the blind men of the famous parable, we each catch a hold of a tiny piece of it -- leg, tail, trunk -- and think we have a handle on it" (18). A powerful force with influence on many aspects of contemporary life, the pharmaceutical industry could be understood through the lens of biomedicalization: Biomedicalization imposes new mandates and performances that become incorporated into one’s sense of self. The subjectivities that arise out of these performances of what it is to be healthy (e.g., proactive, prevention-conscious, neo-rational) suggest how biomedical technoscience indicates a type of governmentality that can enact itself at the level of subjective identities and social relations. (Clarke et al. 182) Disease marketing—prevalent in the 1990s—is no longer needed or effective; health marketing has taken over and pharmaceutical companies are not at the table alone (Elliott 97). Instead of working through disease difference, health marketing attempts to level ground through images and standards that everyone can work towards, asthmatics included. Of course, pharmaceutical marketing simultaneously renders invisible socioeconomic conditions that contribute to asthma incidence, and marginalized populations that struggle to access medication and medical care in the first place. Augmented health works to flatten difference across social, economic, political, and ecological scales, as if these inequalities didn’t matter for disease management. Scholars writing about emergent modes of health—how health is imagined, constructed, studied, and sold—have documented how new health regimes work off potential risk categories, race, class, and gendered ideologies, or hoped-for modes of living. Some are literally “against health” (the title of Metzel and Kirkland’s edited volume). But to be against health, as Metzel writes is not to be against needed treatment (9). To examine the ways in which DTCA or advocacy campaigns promote specific, idealized images of health—images where people are athletic, outgoing, and busy—and question whether these drugs go above and beyond the restoration of health, should not be equated with a statement about whether medication is necessary. Epidemiological evidence and clinical studies are clear that contemporary treatments help reduce the burden of asthma in various ways: through reduced hospitalizations, lower death rates, and better-controlled asthma. Drugs keep many asthmatics relatively symptom-free. The point, rather, is that health is complex, structured by various institutions, actors, politics, and materials. One of the valences of the new health regime is augmented health, seen in the context of this paper at work in DTCA and possibly emerging in other corners of the asthma care arena as well. To date, most writing on augmentation has focused on how advancements in science and technology extend the capacity of human bodies—from prosthetics and fertility drugs, to steroids and life support (Hogle 696). Less has been written on the ways in which chronic conditions like diabetes, heart disease, and asthma—conditions where life hinges on medications, but are common enough that they are deemed unexceptional—produce a rhetoric of augmentation; where the new healthy is augmented living. It’s not the drugs for life rhetoric that works off new risk categories, as Dumit has shown (201); asthmatics are symptomatic, always at risk anyways, and often already on drugs for life. Drugs for chronic conditions like asthma may simply control symptoms, but they’re increasingly sold on the promise of enhancing life capacities as well. As Elliott has observed, it’s part of a move from disease marketing to health marketing (97). The discursive shift in asthma care, and perhaps other chronic disease contexts as well, doesn’t register as enhancement or augmentation because it mirrors the new health norm that is part of the broader context of biomedicalization. As the frame of health shifts, questions about bodies, ethics, and enhancement technologies might need to shift as well. Linda Hogle’s question is apt here: “what is necessary to sustain health? At which point does repair become something more than restorative, and for which (and whose) purposes are interventions defined as 'therapeutic'” (697). Since health norms have become augmented in the last ten years, this question becomes all the more difficult to answer. Within these new health regimes, potential has not only become open-ended, it also seems to be a therapeutic goal. References Arie, Sophie. “What Can We Learn from Asthma in Elite Athletes?” British Medical Journal 344 (2012). Be Smart. Be Well. “The Right Meds Keep Her in the Ring.” Be Smart. Be Well. 14 Aug. 2013. 1 Dec. 2013 ‹http://www.besmartbewell.com/childhood-asthma/tiffany.htm›. Clarke, Adele, Janet Shim, Laura Mamo, Jennifer Fosket, and Jennifer Fishman. “Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S. Biomedicine.” American Sociological Review 68 (2003): 161-194. Dumit, Joseph. Drugs for Life: How Pharmaceutical Companies Define Our Health. Durham: Duke University Press, 2012. Elliott, Carl. Better than Well: American Medicine Meets the American Dream. New York: W.W. Norton & Company, 2012. GlaxoSmithKline. “Advair Commercial – 2012.” 14 Sep. 2013. 1 Dec. 2013 ‹http://www.youtube.com/watch?v=OZ4hgIfU4AI›. GlaxoSmithKline. “GlaxoSmithKline (GSK) Commercial – Asthma.com.” 1 Aug. 2013. 14 Sep. 2013. ‹http://www.youtube.com/watch?v=bvyxbX3Jnp4›. Hogle, Linda. “Enhancement Technologies and the Body.” Annual Review of Anthropology 34 (2005): 695-716. Jackson, Mark. Asthma: A Biography. Oxford: Oxford University Press, 2009. Metzl, Jonathan M., and Anna Kirkland. Against Health: How Health Became the New Morality. New York: New York University Press, 2010. Moorman, J.E., L.J. Akinbami, C.M. Bailey, et al. “National Surveillance of Asthma: United States, 2001–2010. National Center for Health Statistics.” Vital Health Stat 3.35 (2012). Mitman, Gregg. Breathing Space: How Allergies Shape Our Lives and Landscapes. New Haven: Yale University Press, 2007. National Library of Medicine. “Breath of Life.” National Library of Medicine Archives, 1999. 31 Aug. 2013. 1 Dec. 2013 ‹http://www.nlm.nih.gov/archive/20120918/hmd/breath/breathhome.html›.Sinding, Christiane. “The Power of Norms: Georges Canguilhem, Michel Foucault, and the History of Medicine.” In Locating Medical History: Their Stories and Meanings, eds. Frank Huisman and John Harley Warner. Baltimore: Johns Hopkins University Press, 2004. Symbicort. “Symbicort Fishing Video.” 1 Jan. 2013. 13 Sep. 2013 ‹http://www.youtube.com/watch?v=oG9MxLwnapE› . Whitmarsh, Ian. Biomedical Ambiguity: Race, Asthma, and the Contested Meaning of Genetic Research in the Caribbean. Ithaca: Cornell University Press, 2008.

One of the first challenges faced by new Australian Prime Minister, Kevin Rudd, was what to do with the former government’s controversial citizenship test. While a quick evaluation of the test shows that 93 percent of those who have sat it ‘passed’ (Hoare), most media controversy has focussed less on the validity of such a test than whether questions relating to Australian cricketing legend, Don Bradman, are appropriate (Hawley). While the citizenship test seems nothing more that a crude and populist measure imposed by the former Howard government in its ongoing nationalistic agenda, which included paying schools to raise the Australian flag (“PM Unfurls Flag”), its imposition seems a timely reminder of the challenge of understanding citizenship today. For as the demographic structures around us continue to change, so must our understandings of ‘citizenship’. More importantly, this fluid understanding of citizenship is not limited to academics, and policy-makers, but new technologies, the processes of globalisation including a globalised media, changing demographic patterns including migration, as well as environmental challenges that place pressure on limited resources is altering the citizens understanding of their own role as well as those around them. This paper aims to sketch out a proposed new research agenda that seeks to investigate this fluid and heterogenous nature of citizenship. The focus of the research has so far been Sydney and is enveloped by a broader aim of promoting an increased level of citizen engagement both within formal and informal political structures. I begin by sketching the complex nature of Sydney before presenting some initial research findings. Sydney – A Complex City The so-called ‘emerald city’ of Sydney has been described in many ways: from a ‘global’ city (Fagan, Dowling and Longdale 1) to an ‘angry’ city (Price 16). Sarah Price’s investigative article included research from the University of Western Sydney’s Centre of Culture Research, the Bureau of Crime Statistics and interviews with Tony Grabs, the director of trauma at St Vincent’s Hospital in inner city Darlinghurst. Price found that both injuries from alcohol and drug-related violence had risen dramatically over the last few years and seemed to be driven by increasing frustrations of a city that is perceived to be lacking appropriate infrastructure and rising levels of personal and household debt. Sydney’s famous harbour and postcard landmarks are surrounded by places of controversy and poverty, with residents of very backgrounds living in close proximity: often harmoniously and sometimes less so. According to recent research by Griffith University’s Urban Research Program, the city is becoming increasingly polarised, with the wealthiest enjoying high levels of access to amenities while other sections of the population experiencing increasing deprivation (Frew 7). Sydney is often segmented into different regions: the growth corridors of the western suburbs which include the ‘Aspirational class’; the affluent eastern suburb; the southern beachside suburbs surrounding Cronulla affectionately known by local residents as ‘the Shire’, and so on. This, however, hides that fact that these areas are themselves complex and heterogenous in character (Frew 7). As a result, the many clichés associated with such segments lead to an over simplification of regional characteristics. The ‘growth corridors’ of Western Sydney, for example, have, in recent times, become a focal point of political and social commentary. From the rise of the ‘Aspirational’ voter (Anderson), seen to be a key ‘powerbroker’ in federal and state politics, to growing levels of disenfranchised young people, this region is multifaceted and should not be simplified. These areas often see large-scale, private housing estates; what Brendan Gleeson describes as ‘privatopias’, situated next to rising levels of homelessness (“What’s Driving”): a powerful and concerning image that should not escape our attention. (Chamberlain and Mackenzie pay due attention to the issue in Homeless Careers.) It is also home to a growing immigrant population who often arrive as business migrants and as well as a rising refugee population traumatised by war and displacement (Collins 1). These growth corridors then, seem to simultaneously capture both the ambitions and the fears of Sydney. That is, they are seen as both areas of potential economic boom as well as social stress and potential conflict (Gleeson 89). One way to comprehend the complexity associated with such diversity and change is to reflect on the proximity of the twin suburbs of Macquarie Links and Macquarie Fields situated in Sydney’s south-western suburbs. Separated by the clichéd ‘railway tracks’, one is home to the growing Aspirational class while the other continues to be plagued by the stigma of being, what David Burchell describes as, a ‘dysfunctional dumping ground’ whose plight became national headlines during the riots in 2005. The riots were sparked after a police chase involving a stolen car led to a crash and the death of a 17 year-old and 19 year-old passengers. Residents blamed police for the deaths and the subsequent riots lasted for four nights – involving 150 teenagers clashing with New South Wales Police. The dysfunction, Burchell notes is seen in crime statistics that include 114 stolen cars, 227 burglaries, 457 cases of property damage and 279 assaults – all in 2005 alone. Interestingly, both these populations are surrounded by exclusionary boundaries: one because of the financial demands to enter the ‘Links’ estate, and the other because of the self-imposed exclusion. Such disparities not only provide challenges for policy makers generally, but also have important implications on the attitudes that citizens’ experience towards their relationship with each other as well as the civic institutions that are meant to represent them. This is particular the case if civic institutions are seen to either neglect or favour certain groups. This, in part, has given rise to what I describe here as a ‘citizenship surplus’ as well as a ‘citizenship deficit’. Research Agenda: Investigating Citizenship Surpluses and Deficits This changing city has meant that there has also been a change in the way that different groups interact with, and perceive, civic bodies. As noted, my initial research shows that this has led to the emergence of both citizenship surpluses and deficits. Though the concept of a ‘citizen deficits and surpluses’ have not emerged within the broader literature, there is a wide range of literature that discusses how some sections of the population lack of access to democratic processes. There are three broad areas of research that have emerged relevant here: citizenship and young people (see Arvanitakis; Dee); citizenship and globalisation (see Della Porta; Pusey); and citizenship and immigration (see Baldassar et al.; Gow). While a discussion of each of these research areas is beyond the scope of this paper, a regular theme is the emergence of a ‘democratic deficit’ (Chari et al. 422). Dee, for example, looks at how there exist unequal relationships between local and central governments, young people, communities and property developers in relation to space. Dee argues that this shapes social policy in a range of settings and contexts including their relationship with broader civic institutions and understandings of citizenship. Dee finds that claims for land use that involve young people rarely succeed and there is limited, if any, recourse to civic institutions. As such, we see a democratic deficit emerge because the various civic institutions involved fail in meeting their obligations to citizens. In addition, a great deal of work has emerged that investigates attempts to re-engage citizens through mechanisms to promote citizenship education and a more active citizenship which has also been accompanied by government programs with the same goals (See for example the Western Australian government’s ‘Citizenscape’ program ). For example Hahn (231) undertakes a comparative study of civic education in six countries (including Australia) and the policies and practices with respect to citizenship education and how to promote citizen activism. The results are positive, though the research was undertaken before the tumultuous events of the terrorist attacks in New York, the emergence of the ‘war on terror’ and the rise of ‘Muslim-phobia’. A gap rises, however, within the Australian literature when we consider both the fluid and heterogenous nature of citizenship. That is, how do we understand the relationship between these diverse groups living within such proximity to each other overlayed by changing migration patterns, ongoing globalised processes and changing political environments as well as their relations to civic institutions? Further, how does this influence the way individuals perceive their rights, expectations and responsibilities to the state? Given this, I believe that there is a need to understand citizenship as a fluid and heterogenous phenomenon that can be in surplus, deficit, progressive and reactionary. When discussing citizenship I am interested in how people perceive both their rights and responsibilities to civic institutions as well as to the residents around them. A second, obviously related, area of interest is ‘civic engagement’: that is, “the activities of people in the various organisations and associations that make up what scholars call ‘civil society’” (Portney and Leary 4). Before describing these categories in more detail, I would like to briefly outline the methodological processes employed thus far. Much of the research to this point is based on a combination of established literature, my informal discussions with citizen groups and my observations as ‘an activist.’ That is, over the last few years I have worked with a broad cross section of community-based organisations as well as specific individuals that have attempted to confront perceived injustices. I have undertaken this work as both an activist – with organisations such as Aid/Watch and Oxfam Australia – as well as an academic invited to share my research. This work has involved designing and implementing policy and advocacy strategies including media and public education programs. All interactions begin with a detailed discussion of the aims, resources, abilities and knowledge of the groups involved, followed by workshopping campaigning strategies. This has led to the publication of an ‘activist handbook’ titled ‘From Sitting on the Couch to Changing the World’, which is used to both draft the campaign aims as well as design a systematic strategy. (The booklet, which is currently being re-drafted, is published by Oxfam Australia and registered under a creative commons licence. For those interested, copies are available by emailing j.arvanitakis (at) uws.edu.au.) Much research is also sourced from direct feedback given by participants in reviewing the workshops and strategies The aim of tis paper then, is to sketch out the initial findings as well as an agenda for more formalised research. The initial findings have identified the heterogenous nature of citizenship that I have separated into four ‘citizenship spaces.’ The term space is used because these are not stable groupings as many quickly move between the areas identified as both the structures and personal situations change. 1. Marginalisation and Citizenship Deficit The first category is a citizenship deficit brought on by a sense of marginalisation. This is determined by a belief that it is pointless to interact with civic institutions, as the result is always the same: people’s opinions and needs will be ignored. Or in the case of residents from areas such as Macquarie Fields, the relationship with civic institutions, including police, is antagonistic and best avoided (White par. 21). This means that there is no connection between the population and the civic institutions around them – there is no loyalty or belief that efforts to be involved in political and civic processes will be rewarded. Here groups sense that they do not have access to political avenues to be heard, represented or demand change. This is leading to an experience of disconnection from political processes. The result is both a sense of disengagement and disempowerment. One example here emerged in discussions with protesters around the proposed development of the former Australian Defence Industry (ADI) site in St Marys, an outer-western suburb of Sydney. The development, which was largely approved, was for a large-scale housing estate proposed on sensitive bushlands in a locality that resident’s note is under-serviced in terms of public space. (For details of these discussions, see http://www.adisite.org/.) Residents often took the attitude that whatever the desire of the local community, the development would go ahead regardless. Those who worked at information booths during the resident protests informed me that the attitude was one best summarised by: “Why bother, we always get stuffed around any way.” This was confirmed by my own discussions with local residents – even those who joined the resident action group. 2. Privatisation and Citizenship Deficit This citizenship deficit not only applies to the marginalised, however, for there are also much wealthier populations who also appear to experience a deficit that results from a lack of access to civic institutions. This tends to leads to a privatisation of decision-making and withdrawal from the public arena as well as democratic processes. Consequently, the residents in the pockets of wealth may not be acting as citizens but more like consumers – asserting themselves in terms of Castells’s ‘collective consumption’ (par. 25). This citizenship deficit is brought on by ongoing privatisation. That is, there is a belief that civic institutions (including government bodies) are unable or at least unwilling to service the local community. As a result there is a tendency to turn to private suppliers and believe that individualisation is the best way to manage the community. The result is that citizens feel no connection to the civic institutions around them, not because there is no desire, but there are no services. This group of citizens has often been described as the ‘Aspirationals’ and are most often found in the growth corridors of Sydney. There is no reason to believe that this group is this way because of choice – but rather a failure by government authorities to service their needs. This is confirmed by research undertaken as early as 1990 which found that the residents now labelled Aspirational, were demanding access to public infrastructure services including public schools, but have been neglected by different levels of government. (This was clearly stated by NSW Labor MP for Liverpool, Paul Lynch, who argued for such services as a way to ensure a functioning community particularly for Western Sydney; NSWPD 2001.) As a result there is a reliance on private schools, neighbourhoods, transport and so on. Any ‘why bother’ attitude is thus driven by a lack of evidence that civic institutions can or are not willing to meet their needs. There is a strong sense of local community – but this localisation limited to others in the same geographical location and similar lifestyle. 3. Citizenship Surplus – Empowered Not Engaged The third space of citizenship is based on a ‘surplus’ even if there is limited or no political engagement. This group has quite a lot in common with the ‘Aspirationals’ but may come from areas that are higher serviced by civic institutions: the choice not to engage is therefore voluntary. There is a strong push for self-sufficiency – believing that their social capital, wealth and status mean that they do not require the services of civic institutions. While not antagonistic towards such institutions, there is often a belief is that the services provided by the private sector are ultimately superior to public ones. Consequently, they feel empowered through their social background but are not engaged with civic institutions or the political process. Despite this, my initial research findings show that this group has a strong connection to decision-makers – both politicians and bureaucrats. This lack of engagement changes if there is a perceived injustice to their quality of life or their values system – and hence should not be dismissed as NIMBYs (not in my backyard). They believe they have the resources to mobilise and demand change. I believe that we see this group materialise in mobilisations around proposed developments that threaten the perceived quality of life of the local environment. One example brought to my attention was the rapid response of local residents to the proposed White City development near Sydney’s eastern suburbs that was to see tennis courts and public space replaced by residential and commercial buildings (Nicholls). As one resident informed me, she had never seen any political engagement by local residents previously – an engagement that was accompanied by a belief that the development would be stopped as well as a mobilisation of some impressive resources. Such mobilisations also occur when there is a perceived injustice. Examples of this group can be found in what Hugh Mackay (13) describes as ‘doctor’s wives’ (a term that I am not wholly comfortable with). Here we see the emergence of ‘Chilout’: Children out of Detention. This was an organisation whose membership was described to me as ‘north shore professionals’, drew heavily on those who believed the forced incarceration of young refugee children was an affront to their values system. 4. Insurgent Citizenship – Empowered and Engaged The final space is the insurgent citizen: that is, the citizen who is both engaged and empowered. This is a term borrowed from South Africa and the USA (Holston 1) – and it should be seen as having two, almost diametrically opposed, sides: progressive and reactionary. This group may not have access to a great deal of financial resources, but has high social capital and both a willingness and ability to engage in political processes. Consequently, there is a sense of empowerment and engagement with civic institutions. There is also a strong push for self-sufficiency – but this is encased in a belief that civic institutions have a responsibility to provide services to the public, and that some services are naturally better provided by the public sector. Despite this, there is often an antagonistic relationship with such institutions. From the progressive perspective, we see ‘activists’ promoting social justice issues (including students, academics, unionists and so on). Organisations such as A Just Australia are strongly supported by various student organisations, unions and other social justice and activist groups. From a reactionary perspective, we see the emergence of groups that take an anti-immigration stance (such as ‘anti-immigration’ groups including Australia First that draw both activists and have an established political party). (Information regarding ‘anti-refugee activists’ can be found at http://ausfirst.alphalink.com.au/ while the official website for the Australia First political part is at http://www.australiafirstparty.com.au/cms/.) One way to understand the relationship between these groups is through the engagement/empowered typology below. While a detailed discussion of the limitations of typologies is beyond the scope of this paper, it is important to acknowledge that any typology is a simplification and generalisation of the arguments presented. Likewise, it is unlikely that any typology has the ability to cover all cases and situations. This typology can, however, be used to underscore the relational nature of citizenship. The purpose here is to highlight that there are relationships between the different citizenship spaces and individuals can move between groups and each cluster has significant internal variation. Key here is that this can frame future studies. Conclusion and Next Steps There is little doubt there is a relationship between attitudes to citizenship and the health of a democracy. In Australia, democracy is robust in some ways, but many feel disempowered, disengaged and some feel both – often believing they are remote from the workings of civic institutions. It would appear that for many, interest in the process of (formal) government is at an all-time low as reflected in declining membership of political parties (Jaensch et al. 58). Democracy is not a ‘once for ever’ achievement – it needs to be protected and promoted. To do this, we must ensure that there are avenues for representation for all. This point also highlights one of the fundamental flaws of the aforementioned citizenship test. According to the Department of Immigration and Citizenship, the test is designed to: help migrants integrate and maximise the opportunities available to them in Australia, and enable their full participation in the Australian community as citizens. (par. 4) Those designing the test have assumed that citizenship is both stable and, once achieved, automatically ensures representation. This paper directly challenges these assumptions and offers an alternative research agenda with the ultimate aim of promoting high levels of engagement and empowerment. References Anderson, A. “The Liberals Have Not Betrayed the Menzies Legacy.” Online Opinion 25 Oct. 2004. < http://www.onlineopinion.com.au/view.asp?article=2679 >. Arvanitakis, J. “Highly Affected, Rarely Considered: The International Youth Parliament Commission’s Report on the Impacts of Globalisation on Young People.” Sydney: Oxfam Australia, 2003. Baldassar, L., Z. Kamalkhani, and C. Lange. “Afghan Hazara Refugees in Australia: Constructing Australian Citizens.” Social Identities 13.1 (2007): 31-50. Burchell, D. “Dysfunctional Dumping Grounds.” The Australian 10 Feb. 2007. < http://www.theaustralian.news.com.au/story/0,20867,21199266-28737,00.html >. Burnley, I.H. The Impact of Immigration in Australia: A Demographic Approach. Melbourne: Oxford UP, 2001. Castells, M. “European Cities, the Informational Society, and the Global Economy.” New Left Review I/204 (March-April 1994): 46-57. Chamberlain, C., and D. Mackenzie. Homeless Careers: Pathways in and out of Homelessness. Melbourne: RMIT University, 2002. Chari, R., J. Hogan, and G. Murphy. “Regulating Lobbyists: A Comparative Analysis of the United States, Canada, Germany and the European Union.” The Political Quarterly 78.3 (2007): 423-438. Collins, J. “Chinese Entrepreneurs: The Chinese Diaspora in Australia.” International Journal of Entrepreneurial Behaviour & Research 8.1/2 (2002): 113-133. Dee, M. “Young People, Citizenship and Public Space.” International Sociological Association Conference Paper, Brisbane, 2002. Della Porta, D. “Globalisations and Democracy.” Democratizations 12.5 (2005): 668-685. Fagan, B., R. Dowling, and J. Longdale. “Suburbs in the ‘Global City’: Sydney since the Mid 1990s.” State of Australian cities conference. Parramatta, 2003. Frew, W. “And the Most Polarised City Is…” Sydney Morning Herald 16-17 Feb. 2008: 7. Gleeson, B. Australian Heartlands: Making Space for Hope in the Suburbs. Crows Nest: Allen and Unwin, 2006. Gleeson, B. “What’s Driving Suburban Australia?” Australian Policy Online 15 Jan. 2004. < http://www.apo.org.au/webboard/results.chtml?filename_num=00558 >. Gow, G. “Rubbing Shoulders in the Global City: Refugees, Citizenship and Multicultural Alliances in Fairfield, Sydney.” Ethnicities 5.3 (2005): 386-405. Hahn, C. L. “Citizenship Education: An Empirical Study of Policy, Practices and Outcomes.” Oxford Review of Education 25.1/2 (1999): 231-250. Hawley, S. “Sir Donald Bradman Likely to Be Dumped from Citizenship Test.” ABC Local Radio Online. 29 Jan. 2008. < http://www.abc.net.au/am/content/2007/s2148383.htm >. Hoare, D. “Bradman’s Spot in Citizenship Test under Scrutiny.” ABC Local Radio online. 29 Jan. 2008. < http://www.abc.net.au/pm/content/2008/s2149325.htm >. Holston, J. Insurgent Citizenship: Disjunctions of Democracy and Modernity in Brazil. California: Cloth, 2007. Jaensch, D., P. Brent, and B. Bowden. “Australian Political Parties in the Spotlight.” Democratic Audit of Australia Report 4. Australian National University, 2004. Mackay, H. “Sleepers Awoke from Slumber of Indifference.” Sydney Morning Herald 27 Nov. 2007: 13. NSWPD – New South Wales Parliamentary Debates. “South Western Sydney Banking Services.” Legislative Assembly Hansard, 52nd NSW Parliament, 19 Sep. 2001. Portney, K.E., and L. O’Leary. Civic and Political Engagement of America’s Youth: National Survey of Civic and Political Engagement of Young People. Medford, MA: Tisch College, Tufts University, 2007. Price, S. “Stress and Debt Make Sydney a Violent City.” Sydney Morning Herald 13 Jan. 2008: 16. Pusey, M. The Experience of Middle Australia: The Dark Side of Economic Reform. Cambridge: Cambridge UP, 2003. White, R. “Swarming and the Social Dynamics of Group Violence.” Trends and Issues in Crime and Criminal Justice 326 (Oct. 2006). < http://www.aic.gov.au/publications/tandi2/tandi326t.html >. Wolfe, P. “Race and Citizenship.” Magazine of History 18.5 (2004): 66-72.