Journal articles on the topic 'WAKE UP BREATHING'

ABSTRACTAltered sleep architecture and stroke share a reciprocal relationship. More than half of the stroke patients display sleep abnormalities including hypersomnia, insomnia, parasomnia, periodic limb movements, or sleep-disordered breathing. Conversely, one of the major causes of severe organic hypersomnia is acute brainstem strokes, involving thalamic infarctions, which may be reversible over 6–12 months. Here, we report a patient with increased lethargy and drowsiness who was diagnosed to have a right thalamic and hypothalamic ischemic stroke.

BackgroundWe sought to investigate the frequency of wake-up stroke (WUS) and its association with sleep-disordered breathing (SDB) in women.MethodsWithin a population-based study, women with acute ischemic stroke were asked about their stroke symptom onset time. SDB screening was performed with the well-validated ApneaLink Plus device; SDB was defined by a respiratory event index ≥10. Logistic regression was used to test the association between SDB presence and severity and WUS unadjusted and adjusted for potential confounders including prestroke depression and sleep duration.ResultsAmong 466 participants, the median age was 67.0 years (interquartile range [IQR] 58.0, 77.0), 55% were Mexican American, and the median initial NIH Stroke Scale score was 3.0 (IQR 1.0, 6.0). Stroke symptom onset occurred during nocturnal sleep (25.3%), during a nap (3.9%), during wakefulness (65.9%), or unknown (4.9%). In those with SDB screening performed (n = 259), a median of 11 days (IQR 5, 17) poststroke, WUS was not associated with the presence or severity (respiratory event index) of SDB in unadjusted or adjusted analysis.ConclusionsIn this population-based study, WUS represented about 30% of all generally mild severity ischemic strokes in women and was not associated with SDB.

Abstract Introduction Cornelia de Lange syndrome (CdLS) is a rare genetic disorder characterized by variable physical, cognitive, and behavioral characteristics. Sleep disturbances have been frequently reported in CdLS including insomnia, sleep-disordered breathing, intrinsic sleep disorders, and circadian rhythm disorders (CRDs). The characterization and prevalence of CRDs in CdLS remain ill- defined. We report a case of a 13-year-old female with CdLS presenting with advanced sleep wake phase disorder (ASWPD). Report of case(s) A 13-year-old female with a past medical history of CdLS, developmental delay, bilateral cleft palate status post repair presents with inability to fall asleep at night and excessive daytime sleepiness.(EDS) Her sleep history consists of going to bed at 4 pm with no delayed sleep onset. She wakes at 2:30 am which has occurred since infancy. Mother reports the patient will remain awake from 2:30 am until she goes to school at 7:30 am. History is consistent with EDS and sleeping during the day while at school. Total sleep time of approximately 11–12 hours was reported in 24-hour period. History of obstructive sleep apnea, parasomnias, insomnia, restless leg syndrome, and psychotropic medications were not reported. Patient was treated with timed low dose melatonin therapy 0.5 mg at 4 pm and bright light therapy using 10,000 lux for 30 minutes at 7 am and 4 pm. Dim lights starting at 7:30 pm with structured scheduled sleep hygiene ensuring consistent bedtime at 9:30 pm. A consistent wake time at 7 am and no naps during the day was recommended. Follow up visits report successful response to therapy with attainment of desired sleep wake rhythm (bedtime at 9:30 pm and wake time at 7 am) and resolution of sleepiness during the day. Our patient was able to be weaned off of melatonin and light therapy and her circadian rhythm remained entrained. Conclusion Patients with disorder such as CdLS are at risk for circadian rhythm disorders. Our patient responded well to treatment with combined timed phototherapy and low dose melatonin therapy. Better knowledge and characterization of typology of CRDs in CdLS patients could permit a more specific therapeutic approach to sleep disorders in this population. Support (if any) None

Abstract Introduction We present a patient with chronic insomnia, excessive daytime sleepiness, and sleep-related hypoventilation that improved with a wake promoting agent in conjunction with BPAP. Report of Case A 15-year-old male with Cystic Fibrosis (single F508del mutation, positive sweat test, FEV1% of 98%) and Autism who presented with frequent headaches, chronic insomnia, and daytime sleepiness (PDSS of 22). Current medications included albuterol as needed. Sleep history was significant for restless leg symptoms. Labs revealed low serum ferritin. Sleep study two years prior showed an AHI of 3.4 and PMLD of 18.4. After completion of iron therapy and initiation of gabapentin, his chronic insomnia and serum ferritin improved. However, patient continued to have aggressive behavior, headaches, and snoring. Sleep study was repeated and revealed mild OSA with hypoventilation (AHI of 6.41, >28% of total sleep time with TCO2 above 50 mm Hg). Initial serum bicarbonate was 29 mmol/L and progressively increased to 34 mmol/L. Due to evidence of persistent chronic hypoventilation, patient was trialed on BPAP. Subsequent sleep study with BPAP showed an AHI of 0, but with worsening sleep related hypoventilation (TCO2 of 56mmHg, > 70% total sleep time with TCO2 above 50 mm Hg). Genetic, endocrine, and neurological work up for hypoventilation was negative. Due to persistent daytime sleepiness (PDSS of 24), MSLT was performed and showed evidence of hypersomnia. Modafinil was then initiated. With the combination of nocturnal BPAP use and Modafinil, daytime sleepiness improved (PDSS of 15) and he had normalization of CO2 and bicarbonate levels. Conclusion We present a patient with CF, with minimal lung disease, who demonstrated a negative work up for sleep related hypoventilation, in which dysregulation of control of breathing improved with the use of a wake promoting agent in conjunction with BPAP.

Abstract Introduction Diurnal patterning of autonomic function in paroxysmal atrial fibrillation (PAF) and sleep disordered breathing (SDB) is unknown. We hypothesize heart rate variability (HRV) as surrogates of autonomic function, exhibit diurnal differences in PAF relative to SDB severity and treatment. Methods We leveraged the Sleep Apnea and Atrial Fibrillation Biomarkers and Electrophysiologic Atrial Triggers (SAFEBEAT,NCT02576587) study focused on participants with PAF and SDB (apnea hypopnea index,AHI≥15,3% oxygen desaturation hypopnea). Attended 16-channel polysomnography (PSG) and continuous ECG monitoring (Heartrak Telemetry®) for 7-21 days was performed at baseline and after 3-months of continuous positive airway pressure (CPAP). Linear mixed-effects models (least square means,95%CI) were used to assess relationships between daily average HRV measures (frequency domain:LF,HF,LF/HF;time domain:MNN,RMSSD,SD1,SD ratio and novel non-linear:DFA-alpha measures) with SDB (AHI),%sleep time with SaO2<90%(TRT<90): per 5-unit increase),effect of 3-month CPAP relative to sleep-wake and statistical interaction of sleep-wake. Analyses were conducted using SAS version v.9.4, Cary, NC. Results The analytic sample was comprised of 33 cases with PAF and SDB:61.1±11.7 years,62.5% male, BMI:33.9±7.2kg/m2,75% Caucasian,AHI 15.1 (IQR: 4.4,29.4) and 68.8% on atrioventricular nodal blocking medications. AHI was associated with frequency (HF:0.08[0.01,0.16] and LF/HF:-0.11[-0.20, -0.01]), time (SD1:0.08[0.02,0.14] and SD ratio: 0.09[0.04,0.14]) and non-linear (DFA-alpha1: -0.02[-0.036,-0.003]) domain measures during wake, but not sleep. Significant sleep-wake and AHI as well as TRT<90 interactions relative to HRV measures were observed (p≤0.001). Only SD ratio was associated with TRT<90 (0.12[0.03,0.24]). Baseline to follow-up CPAP time domain measures were altered mainly during wake versus sleep with MNN increased 0.13: [0.08,0.19],p<0.001; RMSSD increased 0.13 [0.08,0.19], p<0.001; SD1 increased 30% [0.09,0.55], p=0.004; SD ratio increased 20% [0.01,0.43], p=0.033,and also frequency domain: HF increased 33%[0.03,0.72], p=0.028. Conclusion SDB defined by AHI--more so than nocturnal hypoxia--was associated with surrogate autonomic measures impacted by CPAP intervention during wake and not sleep in PAF. SDB-related autonomic influences in PAF appear to be more pronounced during wakefulness suggesting long-term potentiation-like influences. Support This study was supported by the National Heart, Lung and Blood Institute (NHLBI) [Grant R01 HL108493] and National Institutes of Health (NIH) National Center for Research Resources [Grant UL1 RR024989]

AbstractIntroductionThe 2011 Great East Japan Earthquake caused major disruptions in the provision of health care, including that for patients with sleep-disordered breathing (SDB) using a nasal continuous positive airway pressure (nCPAP) device. This study investigated the ability of SDB patients to continue using the nCPAP device in the weeks immediately following the earthquake, whether inability to use the nCPAP device led to symptom relapse, and measures that should be taken to prevent disruptions in nCPAP therapy during future disasters.HypothesisIf nCPAP devices cannot be used during disasters, SDB patients’ health will be affected negatively.MethodsWithin 14 days of the disaster, 1,047 SDB patients completed a questionnaire that collected data regarding ability to use, duration of inability to use, and reasons for inability to use the nCPAP device; symptom relapse while unable to use the nCPAP device; ability to use the nCPAP device use at evacuation sites; and recommendations for improvement of the nCPAP device.ResultsOf the 1,047 patients, 966 (92.3%) had been unable to use the nCPAP device in the days immediately following the earthquake. The most common reason for inability to use the nCPAP device was power failure, followed by anxiety about sleeping at night due to fear of aftershocks, involvement in disaster-relief activities, loss of the nasal CPAP device, and fear of being unable to wake up in case of an emergency. Among the 966 patients, 242 (25.1%) had experienced relapse of symptoms, the most common of which was excessive daytime sleepiness (EDS), followed by insomnia, headache, irritability, and chest pain.ConclusionDeveloping strategies for the continuation of nCPAP therapy during disasters is important for providing healthy sleeping environments for SDB patients in emergency situations.MitoF, NishijimaT, SakuraiS, KizawaT, HosokawaK, TakahashiS, SuwabeA, AkasakaH, KobayashiS. Effects of CPAP treatment interruption due to disasters: patients with sleep-disordered breathing in the Great East Japan Earthquake and tsunami area. Prehosp Disaster Med. 2013;28(6):547-555.

Abstract Introduction Frontotemporal dementia (FTD) is a degenerative process and,as the name implies, involves the frontal and temporal lobes of the brain. Patients with FTD make up 10–15% of all cases of dementia and 20% diagnosed before age 65, however not much is reported about sleep disturbances in these patients. Given the area of neuronal loss one would expect that sleep may be influenced early and by issues in arousal mechanisms and in breathing pattern. This study examined the polysomnography (PSG) reports of patients with a diagnosis FTD. Methods A retrospective chart review was performed to identify patients with both a diagnosis of FTD and having undergone a PSG. 23 patients were identified as fulfilling both requirements. Data recorded included, diagnosis, age at time of PSG, Epworth sleepiness scale (ESS), total sleep time (TST), wake after sleep onset (WASO), sleep latency (SL), REM sleep latency, sleep efficiency (SE), percentage of stage N1, N2, N3, and REM sleep, apnea-hypopnea index (AHI), presence of Cheyne-Stoke breathing, periodic limb movement index, and presence of REM without atonia. Results Patient age ranged from 57–85 years. Average ESS was 8.8 with only 5 patients reported excessive daytime sleepiness(as assessed by ESS). The average TST was 290 minutes, average SL was 37.9 minutes, average WASO was 147.5 minutes, and average sleep efficiency was 60.3%. Patients spent the majority of time in N2 sleep with an average of 68.3% of the time spent in N2. The average time spent in N3 was 9.6% of sleep. 8.9% of sleep was spent in REM. 83% of patients were diagnosed with sleep apnea (as defined by an AHI > 5), with an average AHI of 20.2 events/hour. Cheyne-Stokes breathing was only noted in 4 of the 23 patients, or 17%. Periodic limb movements of sleep were noted in 48% of the patients (n=11). REM without atonia or RBD was not noted for any patients. Conclusion This study shows that patients with FTD suffer from typical sleep disturbances, however there is a high prevalence of sleep apnea as well as PLMS. In addition, patients with FTD have decreased sleep efficiency with increased WASO. Support (if any):

The number of people who complain of sleep disturbances is steadily increasing. An understanding of sleep-related factors is required to address sleep problems. This survey study investigated the sleep habits and sleeping symptoms relating to the comfort and support characteristics of pillows and the relationship between sleep quality and pillow design factors. The study utilized data from 332 participating Korean adults aged 20–76 years (mean age ± SD: males, 40.4 ± 15.2; females, 42.9 ± 15.4). We developed a questionnaire that evaluated sleep habits (sleep duration, bedtime, wake-up time and sleeping position); sleeping symptoms (snoring or coughing, breathing and sleepiness during waking hours) based on the Korean version of the Pittsburgh Sleep Quality Index (PSQI-K) questionnaire; and pillow-related factors (support, comfort, fatigue, height and shape) from existing pillow studies. The average sleep duration was 6.8 h, with more than half (52%) of participants sleeping in the supine position. The overall score for sleep quality was considered poor (4.84 points on a seven-point Likert scale), with some degree of sleepiness during waking hours (4.4 points on a seven-point Likert scale). Females went to bed earlier than males and were more likely to sleep in the lateral position compared to males. The number of toss and turn or waking events during sleep increased with age, and older individuals went to sleep earlier and woke up earlier. Among the symptoms of fatigue, pain, discomfort with changing position, snoring, coughing and breathing discomfort, participants reported their highest levels of discomfort due to sleepiness after waking, and they experienced the least head pain. Participants who used a regular-type pillow had poorer satisfaction on multiple comfort and support factors (support, comfort, height suitability, shape suitability) compared with those who used a functional-type pillow. Less head fatigue, less neck fatigue and less shoulder pain had significant effects on sleep quality. To reduce neck fatigue and shoulder pain, designers should consider the height for neck support in the lateral position. To reduce neck fatigue, it is desirable to use materials like latex or memory foam that provide neck support, which can improve sleep quality. The findings of this study contribute to a better understanding of sleep habits and characteristics of pillow comfort and provide practical guidelines for better pillow designs.

Background. The success of respiratory support depends on the effectiveness of improving gas exchange, reducing lung damage, and adaptation of the respirator. Reduction of lung damage has previously been reported in the context of ventilator-associated injury: barotrauma in case of high plateau pressure and driving pressure, volume trauma in case of large tidal volume, atelectasis trauma due to the cyclic collapse of lungs on exhalation and opening on inspiration. Objective. To describe the features of lung damage during mechanical lung ventilation (MLV) and the possibility of its prevention. Materials and methods. Analysis of literature sources on this topic. Results and discussion. The main causes of “air hunger” breathing type and shortness of breath include hypoxia, acidosis, increased anatomical and functional dead space, psychomotor agitation and fear. Metabolic acidosis is compensated by hyperventilation and respiratory alkalosis, but it is treated by improving oxygenation. High-flow oxygenation helps to leach CO2 from the dead space. Psychomotor agitation and pain aggravate shortness of breath, so all components of these processes should be influenced by effective analgesia, providing the patient with a comfortable body position (especially obese people), ensuring the absence of hunger and thirst, creating conditions for night sleep and more. If all these measures are taken, but the patient’s agitation is maintained, sedation should be considered. Propofol and dexmedetomidine are increasingly used for short-term sedation. Approaches to sedation have been changing abroad in recent years. First, non-pharmacological methods are used and only then – pharmacological ones. First of all, it is recommended to achieve analgesia, and then – sedation. It is advisable to maintain moderate sedation (from 0 to -2 on the RASS scale) and avoid deep sedation (from -3 to -5 points on the RASS scale). Sedation should be stopped each morning for the wake-up test and the respirator quitting test. To improve the immediate consequences of treatment (duration of MLV and stay in the intensive care unit), it is advisable to minimize the use of benzodiazepines and prefer propofol or dexmedetomidine. The depth of sedation should be constantly monitored, however, even experienced physicians may not always be able to detect asynchrony and excessive sedation. Asynchrony is associated with the increased mortality and prolonged weaning. To assess the intensity of the patient’s respiratory effort, the index of rapid shallow breathing, the maximum vacuum in the airways and the pressure in 0.1 second after the start of the breathing attempt are used. If the latter exceeds 3.5 cm H2O, it indicates the excessive respiratory effort of the patient (Telias I. et al., 2020). Conclusions. 1. The term “self-induced lung injury” has become widely used in the practice of anesthesiologists. 2. The need for respiratory support is determined primarily by the patient’s breathing efforts. 3. The ability to timely identify and respond to asynchrony helps to avoid self-induced lung damage.

This study focused on the segmentation effects of an artificial intelligence-based algorithm of CT images, to detect the bile duct injury (BDI) after laparoscopic cholecystectomy (LC) under dezocine anesthesia. This study was based on the maximum between-class variance (Otsu) algorithm; it introduced the image grayscale mapping method to increase the accuracy of the target area segmentation within the CT image and compare the segmentation effect with the threshold segmentation and the regional growth segmentation algorithm. 46 patients treated with laparoscopic cholecystectomy (LC) were used as research objects, and all patients were inspected in the abdominal CT examination. According to the anesthetic drug selection, patients were divided into control group (conventional anesthesia) and dezocine group (conventional anesthesia + dezocine), with 23 cases in each group. And it compared the difference between the respiratory recovery time, the wake time, the tube time, and the postoperative 3, 6, 12, and 24 h after surgery, and complication after LC evaluation of bile duct injury (BDI). It was found that the algorithm in this study can segment the target area in CT image accurately. Compared with the threshold segmentation and region growing segmentation algorithms, its Dice similarity coefficient (DSC) and Jaccard similarity coefficient (JSC) were higher ( P < 0.05 ). There was no statistically significant difference in postoperative spontaneous breathing recovery time, wake-up time, and extubation time between the dezocine group and the control group ( P > 0.05 ), but in the dezocine group, the visual analogue scale (VAS) scores at 3, 6, 12, and 24 hours after the surgery were lower ( P < 0.05 ). 27 patients developed BDI after the surgery, and they were classified as per the Strasberg classification standard. It was found that 6 cases were evaluated as type A, 4 cases were type B, 2 cases were type C, 6 cases were type D, and 9 cases were type E. It was concluded that the algorithm in this study can segment the target area of the CT image accurately, assisting the doctor in diagnosis. The use of dezocine before LC can effectively relieve patients’ postoperative pain. This study provides a basis for the diagnosis and treatment of gallbladder disease and the detection of complications.

Abstract Introduction Excessive daytime sleepiness (EDS) is a common symptom present in several clinical, mental and sleep disorders. However, its subjective metrics have been criticized in the literature due to lack of association with disorder severity, or disagreement with objective measures. Epworth Sleepiness Scale (ESS) is a widely used questionnaire to evaluate EDS, however it may not be sufficient as a sole measure to identify cases of somnolence in the general population. Study objectives: To investigate the association between EDS with socio-demographic, body composition and PSG measures in the general population of São Paulo, Brazil. Methods 1,042 participants from a population-based epidemiological study underwent full in-lab PSG, questionnaires (ESS, fatigue, quality of life, depression and anxiety scales), bio impedance, socio-demographic and anthropometric measures at baseline and in the follow-up 9 years later. A univariate linear regression analysis including the whole sample (baseline and follow-up) was performed to analyze predictors of EDS and ESS score in the follow-up was the dependent variable. All variables with a p-value &lt;0.15 were included in an exploratory factor analysis (principal component analysis with Varimax rotation) to assess the factorial structure of EDS. Results The results supported a five-factorial structure associated with EDS as follows: Factor 1 - Quality of life (Physical and Psychological domains of WHOQOL), Factor 2 – Fatigue (questions from Chalder Fatigue Scale concerning weakness, tiredness, lack of energy and less strength in the muscles), Factor 3 – PSG – sleep duration (wake after sleep onset, sleep efficiency, total time spent awake), Factor 4 – PSG – sleep structure (arousal index, N1 and N3 duration), Factor 5 – Body composition (body mass index). PSG variables related to sleep disordered breathing and movement disorders were not associated with EDS. Conclusion EDS measured by ESS was associated with domains other than sleep disorders in the general population. ESS metrics was significantly associated with fatigue and sleep duration. Support (if any) Associação Fundo Incentivo à Pesquisa (AFIP), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES – Processo 88887.468428/2019-00).

Introduction: Methadone therapy is the mainstay of treatment of addict patients. The most common side effects are: dizziness, drowsiness, vomiting, sweating, dry mouth and constipation. The more serious complications that can be observed are: sleep apnea, аbnormal heart rhythms, respiratory problems, euphoria, disorientation, anxiety, seizures and more. Purpose: The purpose of this study is to determine the correlation between methadone maintenance treatment and sleep apnea in addict patients. Materials and methods: The subject of the study are 81 methadone-treated drug-dependent patients, mean age 39 ± 9,07 years. Results: The answers we received: 79% (64) of drug addicts have problems with sleep; 30.9% of them (25) reported having insomnia; 44.4% (36) experience morning fatigue; 56.8% (46) of the respondents said they were drowsy during the day and 63% of the respondents reported a change in mood; 21% (17) had a short sleep, and 26% (21)reported snoring and 18 of them have loud bothering snoring; 68% answered that they don't have problems with falling asleep and only 21% don’t wake up frequently in the evening. In 83.9% nobody noticed cessation of breathing during sleep. 73.8% never nodded off or fallen asleep while driving a vehicle. 16.1% have been treated for high blood preasure, and only 2.5% have obesity. Conclusions: Our survey found that there is a correlation between methadone therapy and sleep of patients. The key to improving the condition and reducing the risk of central sleep apnea is the monitoring of patients, as well as a combination of different types of treatment.

Abstract Introduction Presence of sleep onset REM episodes often raises concerns of narcolepsy. However other conditions have shown to have presence of sleep on REM episodes which include but not limited to obstructive sleep apnea, sleep wake schedule disturbance, alcoholism, neurodegenerative disorders, depression and anxiety Report of Case Here we present a case of 30 year old female with history of asthma, patent foraman ovale, migraine headache, and anxiety who presented with daytime sleepiness, falling asleep while at work, occasional scheduled naps, non-restorative sleep, sleep paralysis, and hypnopompic hallucination. Pertinent physical exam included; mallampati score of 4/4, retrognathia, high arched hard palate, crowded posterior oropharynx. She had a score of 16 on Epworth sleepiness scale. Patient previously had multiple sleep latency test at outside facility which revealed 4/5 SOREM, with mean sleep onset latency of 11.5 minutes. She however was diagnosed with narcolepsy and tried on modafinil which she failed to tolerate. She was tried on sertraline as well which was discontinued due to lack of benefit. She had repeat multiple sleep latency test work up which revealed 2/5 SOREM, with mean sleep onset latency was 13.1 minutes. Her overnight polysomnogram prior to repeat MSLT showed SOREM with sleep onset latency of 10 minutes. Actigraphy showed consistent sleep pattern overall with sufficient sleep time but was taking hydroxyzine and herbal medication. Patient did not meet criteria for hypersomnolence disorder and sleep disordered breathing. Conclusion There is possibility her medication may have played pivotal role with her daytime symptoms. We also emphasize SOREMs can be present in other disorders such as anxiety in this case and not solely in narcolepsy

Background: Sleep apnea is a condition that interrupts breathing while sleeping, usually caused by an obstruction blocking the back of the throat so that the air cannot reach the lungs. The brief cessation in breath automatically forces individuals to wake up and restart breathing. This can happen many times during the night, making it hard for the body to get enough oxygen, and impacts the sleep quality. It is the most common type of sleep disorder breathing.Objectives: The present study was designed to investigate the effects of obstructive sleep apnea (OSA) on different mental, physical and nervous disorders which are manifested in such patients. This study would not only benefit in ascertaining the causes of OSA through assessment of higher mental functions of autonomic and peripheral nervous systems but also in the development of algorithm for estimation of degree of damage to the nervous system with severity of OSA.Methods: A total of 1365 consecutive participants participated in this study at the Department of Pulmonary Medicine, Deccan College of Medical Sciences, Hyderabad, Telangana State, India for suspected sleep disordered breathing (SDB) between October 2012 and February 2016. In this cohort, 1140 participants were deemed ineligible, as per the inclusion criteria. Therefore, 225 patients were considered in the study along with 75 control subjects, who were healthy individuals. The cohort was diagnosed by an experienced pulmonologist for the symptoms of snoring and daytime somnolence. The data included documentation of age, gender, weight, height, BMI, waist and neck circumference, and clinical data such as history of apnea, insomnia, dyslipidemia, hypertension, and coronary heart disease. All participants underwent overnight polysomnography (PSG) in sleep laboratory. The cognitive function tests consisted of mini-mental state examination and by employing the depression questionnaire (Using Zung self report depression scale). The autonomic function tests were performed. Variabilities in heart rate were determined. Brain natriuretic peptide (BNP) levels in the blood were measured.Results: The study group had an AHI ≥5 per hour of sleep while the control group had AHI <5 per hour of sleep. Overall, patients in the OSA cohort were older compared to those in the Control cohort. The overnight polysomnography values indicated distinct differences among the parameters of the analysis depending upon the category of the patient (i.e., mild, moderate and severe). Oxygen saturation in blood during both REM and NREM sleep stages clearly indicated lower oxygen in patient cohort than the control group. The cognitive function tests revealed that in comparison to the control group, OSA patients had significantly impaired cognition. OSA patients had significantly higher (p ≤0.05) depression. Motor action, muscle action potential and nerve action potential was significantly lower (p ≤0.05) than that of the control group of healthy patients. The plasma BNP in OSA patients was significantly higher (p ≤0.05) than control subjects. RR intervals in the patient group were significantly shorter than in the control group. The blood pressure of the OSA patients in general was relatively higher than the control group, both during the postural response and in handgrip test.Conclusions: Among the enrolled individuals, those with severe OSA were affected in all faculties, namely, cognitive abilities and health attributes; and had high BNP levels in their blood. In aggregate, OSA patients can be alleviated from the syndrome, if accurate diagnosis is made on time. This study developed an algorithm which would aid the clinicians in early detection of OSA symptoms and mitigate the prognosis of the syndrome. Journal of Gandaki Medical CollegeVolume, 09, Number 2, July December 2016, 29-37

Abstract Introduction Snoring can disturb the sleep of snorers as well as their bed partners. Recent technological advances allow objective measurement of sleep and snoring in the comfort of the bedroom. This study examined effects of a non-medical contactless snoring solution on snoring and sleep in snorers and their partners. Methods Self-reported snorers (n=29; 72% male; age 25-59 years, avg. 43; BMI&lt;30) with non-snoring bed partners tracked their snoring nightly with the Do I Snore or Grind app while using the snoring solution at home (527 total nights across participants). During this time, partners tracked their own sleep nightly using ResMed S+. In addition, self-report data were collected from both snorers and partners. A within-subjects, pre-post design was used, comparing a 2-week baseline period to 2 weeks of nightly product use. Multilevel regression and paired t-tests were used to test for statistical significance. The snoring solution (Smart Nora) included a pillow insert that gently inflates when early sounds of snoring are detected, enabling breathing to return to normal. Results Objectively-measured average snoring reduced from 10% of the night when not using the product to 9% during the first week of use and 7% during the second week of use (p&lt;.05). Partners perceived the snoring as less loud and less severe when the product was used. At the end of the study, no partner described the snoring as severe. Objectively-measured sleep of partners revealed a 16% decrease in wake after sleep onset (p&lt;.05). Prior to product use, they spent an average of 38 minutes awake after falling asleep (approximately 9% of their sleep period). This decreased to 34 minutes during the first week of product use and to 32 minutes during the second week. Product use also led to improvements in the perceived sleep of snorers and their partners, including ability to sleep through the night without waking up, overall sleep quality, and feeling rested upon waking in the morning (all ps&lt;.05). Conclusion By reducing the amount of snoring, the contactless snoring solution improved objectively-measured sleep in snorers’ bed partners. Also, the perceived sleep of both snorers and their partners improved. Support (if any) Smart Nora

Abstract Introduction Sleepiness impacts health and functioning, but despite available treatments, many do not seek care. Beliefs and attitudes about treatments for sleepiness and other sleep problems may be useful to know in designing and targeting interventions. Methods N=28 participants with excessive daytime sleepiness (ESS&gt;=10) but no other major medical problems were recruited from the community. They were administered an Epworth Sleepiness Scale and Fatigue Severity Scale at baseline, and asked about a wide range of beliefs/attitudes about mitigating sleepiness, and whether they Strongly Agree(SA), Agree(A), Disagree(D), or Strongly Disagree(SD) with them. Ordinal logistic regressions examined agreement associated with baseline sleepiness and fatigue, adjusted for age, sex, and race/ethnicity (nominal significance p&lt;0.05). Results When asked which strategies are helpful for dealing with or fixing daytime sleepiness, baseline agreement was as follows: Just “power through it” (SA:9%,A:55%,D:32%,SD:5%). Caffeine (SA:18%,A:55%,D:27%). Vigorous exercise (SA:9%,A:36%,D:55%). Mild or moderate movement or exercise (SA:14%,A:82%,D:5%). Trying to get better sleep at night (SA:36%,A:64%). Eating or drinking something to help “wake you up” (SA:27%,A:45%,D:23%,SD:5%). Napping (SA:27%,A:64%,D:9%). Giving up and letting yourself be sleepy (SA:9%,A:42%,D:45%,SD:5%). Improve your diet/eat healthy (SA:42%,A:55%,D:5%). Relaxing activities at night (SA:27%,A:68%,D:5%). Meditation, breathing exercises, or other relaxation techniques (SA:45%,A:45%,D:9%). Watching TV, browsing the internet, or other distracting activities (SA:5%,A:36%,D:45%,SD:14%). Just keep moving (SA:9%,A:55%,D:42%,SD:5%). Setting alarms (SA:18%,A:68%,D:14%). Take prescription medication to improve sleep (SA:5%,A:27%,D:42%,SD:27%). Take over-the-counter medication to improve sleep (SA:5%,A:27%,D:59%,SD:9%). Take prescription stimulant medication (SA:5%,A:32%,D:45%,SD:18). Take over-the-counter stimulant medication (SA:5%,A:27%,D:55%,SD:14%). Take prescription medication that reduces daytime sleepiness (SA:5%,A:36%,D:41%,SD:18%). Take over-the-counter medication that reduces daytime sleepiness (SA:5%,A:27%,D:50%,SD:18%). Those with higher levels of baseline sleepiness were more likely to endorse the following as good strategies to handle daytime sleepiness, “Take over-the-counter medication to improve sleep” (oOR=1.55, p=0.04), “Take prescription medication to improve sleep” (oOR=1.49, p=0.01), and “napping” (oOR=2.55, p=0.03). Those with higher baseline fatigue were less likely to endorse “just ‘powering_through’” (oOR=0.81, p=0.02) as a good strategy of handling daytime sleepiness. Conclusion Real-world beliefs and attitudes about ways of mitigating effects of sleepiness range from medical to behavioral. Those with greater baseline sleepiness may be more amenable to medication. Support (if any) This work was supported by Jazz Pharmaceuticals

Background. Sedation is a controlled medical depression of consciousness with the preservation of protective reflexes, independent effective breathing and response to physical stimulation and verbal commands. Sedation is indicated for patients in the intensive care unit in presence of agitation, delirium, withdrawal syndrome of alcohol, drugs or other potent medications and the need to protect the brain (blunt traumatic brain injury, posthypoxic encephalopathy). In addition, at the request of the patient, sedation can be used during invasive diagnostic and treatment procedures. Objective. To describe the role of dexmedetomidine in modern anesthesiology and intensive care. Materials and methods. Analysis of literature data on this issue. Results and discussion. When performing sedation, one should balance between the excessive sedation and its absence. Excessive sedation is accompanied by the lack of contact with the patient, inability to assess the neurological status of the patient, and respiratory depression. If the patient is optimally sedated, he is calm and able to cooperate; he is also adapted to mechanical lung ventilation and other procedures. The target level of sedation according to the Richmond excitation-sedation scale is from 0 to -1. Drugs such as benzodiazepines (diazepam, midazolam, lorazepam), barbiturates (sodium thiopental), propofol, ketamine, inhaled anesthetics (sevoflurane, dexflurane), dexmedetomidine, opioids (morphine, fentanyl, remifentanyl) are used for sedation. Dexmedetomidine is a highly selective α2-adrenoagonist, so it has anxiolytic, sedative, antinociceptive, sympatholytic, and hypothermic actions. In addition, this drug reduces heart rate, suppresses tremor and increases diuresis. The sedative effect of dexmedetomidine is due to the inhibition of neuronal activity in the locus coeruleus of the brain stem. The condition caused by dexmedetomidine is similar to the natural sleep. The use of dexmedetomidine allows to achieve the target level of sedation in a higher percentage of cases than the use of other drugs (propofol, midazolam) (Jacub S.M. et al., 2012). Cooperative sedation is a sedation with the possibility of interaction of the patient with the medical staff. Compared to other drugs, dexmedetomidine increases the patient’s ability to wake up and quickly orient, after which the patient can quickly return to a state of sedation. One of the major complications of critically serious diseases and their treatment is the deterioration of cognitive abilities. Dexmedetomidine has been shown to improve the patient’s cognitive performance by 6.8 points on the John Hopkins scale. In contrast, propofol reduces cognitive function by an average of 12.4 points (Mirski M.A. et al., 2010). Dexmedetomidine has no respiratory depressant effect. Patients on mechanical ventilation do not require discontinuation of dexmedetomidine prior to extubation. Importantly, dexmedetomidine increases coronary blood flow, reduces the incidence of perioperative myocardial ischemia and the risk of perioperative cardiac death. Dexmedetomidine reduces the intensity of pain in the postoperative period and the need for opioids, the incidence of delirium, and the duration of mechanical ventilation. The financial and economic reasonability of dexmedetomidine use has been proved. Conclusions. 1. Sedation is indicated for patients in the intensive care unit in presence of agitation, delirium, withdrawal syndrome and the need to protect the brain, as well as during invasive diagnostic and treatment procedures. 2. The target level of sedation is from 0 to -1 on the Richmond excitation-sedation scale. 3. Dexmedetomidine is a highly selective α2-adrenoagonist, which has anxiolytic, sedative, antinociceptive, sympatholytic, and hypothermic action. 4. Dexmedetomidine increases coronary blood flow and reduces the incidence of perioperative myocardial ischemia, the risk of perioperative cardiac death, pain, delirium incidence and the duration of mechanical ventilation.

A case of phobic dyspareunia is described. We are talking about a 22-year-old girl whose genital pains first arose 2 years ago during intercourse with a man whose penis length was 25 cm. She had only 5 intercourses with him, and then because of these pains interrupted the relationship with him. Now she is dating a 22-year-old guy who lives in another city, and they come to visit each other. Genital pains and burning in the vagina occur in her not only during intercourses with him and after their end, but even when they are in different cities. In the latter case, they arise when she is planning a trip to another city, involving sexual contacts with her boyfriend (wakes up at night and experiences genital pain and burning sensation “to tears”). Because of this, she cannot sleep. When such a trip is not supposed, then she does not have pain and burning sensation in the genitals. It so happens that the patient comes to her boyfriend, but they do not perform vaginal intercourse, and everything is limited to petting and oral sex. This is preceded by her request to him, and he is sympathetic to her problem. But pains in the genitals occur even with cunnilingus, if not only the clitoris but also the vagina is involved (“bakes, pricks, gives birth to hedgehogs”). She reports that it so happens that pains arise when she comes to her boyfriend, but the matter has not yet come to sexual contact. Before intercourses, she notes the presence of a fear of pain associated with their implementation. This fear is accompanied by tension in the muscles of the body and difficulty in breathing. Currently, sexual desire is sharply weakened, which can be explained by the presence of dyspareunia. During the examination by the gynecologist, no profile pathology was revealed in the patient. Appropriate cognitive influences and 10 sessions of hypnosuggestive programming were carried out. As a result of the therapy, she stopped avoiding sexual intercourses, began to live a regular sex life, pain during and after intercourses practically ceased to arise, libido was increased.

<b><i>Background:</i></b> Management of wake-up stroke (WUS) is always a challenge as no clear time of onset could be ascertained, and how to choose an appropriate therapy remains unclear. Sleep-disordered breathing (SDB) has been regarded as a potential risk factor to WUS, yet no consensus was achieved. Motivated by the need for a deeper understanding of WUS and its association with sleep apnea, meta-analyses summarizing the available evidence of respiratory events and indices were conducted, and sensitivity analysis was also used for heterogeneity. <b><i>Methods:</i></b> Electronic databases were systematically searched, and cross-checking was done for relevant studies. Collected data included demographic characteristics, and sleep apnea parameters were extracted with stroke patients divided into WUS and NWUS groups. Clinical data of stroke patients accompanied with sleep apnea syndrome (OSA, SAS, and severe SAS) were also extracted for meta-analysis. <b><i>Results:</i></b> A total of 13 studies were included in the analysis. The meta-analysis results showed that OSA, SAS, and severe SAS were significantly higher in WUS patients. A significantly higher AHI (WMD 7.74, 95% CI: 1.38–14.11; <i>p</i> = 0.017) and ODI (WMD of 3.85, 95% CI: 0.261–7.438; <i>p</i> = 0.035) than NWUS patients was also observed in the analysis of respiratory indices. <b><i>Conclusion:</i></b> WUS patients have severer SDB problems compared to NWUS patients suggesting that respiratory events during sleep might be underlying the induction of WUS. Besides, the induction of WUS was significantly associated with men rather than women. Therefore, early diagnosis and management of potential WUS patients should benefit from the detection of SDB status and respiratory effects.

AbstractCraniopharyngiomas are rare solid or mixed solid and cystic tumors that arise from Rathke’s pouch remnants along the pituitary-hypothalamic axis, from the sella turcica to the brain third ventricle. Both the tumor and its treatment can lead to significant neurological and endocrinological complications. Due to the essential role of the hypothalamus in the complex neurophysiologic process of sleep, tumors involving the hypothalamic area may be responsible for disturbances in sleep–wake regulation with alterations in the circadian rhythm, sleep fragmentation, and increased daytime sleepiness. We report two cases of patients with craniopharyngioma, who came to our attention due to the occurrence of episodes characterized by psychomotor slowing and afinalistic limb movements, temporal and spatial disorientation, psychomotor agitation, and oneiric stupor like episodes. A comprehensive clinical data collection and a targeted diagnostic work-up led to a diagnosis of severe sleep disorder characterized by hypersomnia, altered sleep–wake rhythm, and sleep-related breathing disorder. In addition, the polysomnography revealed peculiar alterations in the sleep structure. The diagnostic work-up lead to an accurate differential diagnosis between epileptic seizures and episodes expressions of sleep disturbances. These clinical features can be challenging to diagnose and can lead to misdiagnosis and inappropriate treatment. Diagnosis of sleep disorders is crucial, considering the impact of sleep on general health, cognition, and neuropsychological functioning. These findings support the need to incorporate a comprehensive sleep evaluation in childhood brain tumor involving the suprasellar/hypothalamic region.

Sleep apnea disease is a disease at the respiration system in a human that dangerous and has a high mortality rate. There is two sleep apnea, the first is central sleep apnea and then obstructive sleep apnea, basically sleep apnea is a condition that somebody stop breathing when they were sleeping for a few second, sleep apnea caused by the relaxation of respiration muscle. When sleep apnea comes back, sleep apnea patients need to wake up from and breathe normally again. This system is made to provide some mechanism outside of the human body to help obstructive sleep apnea patient woke up from their sleep and breathe well. Furthermore, with this system, might patients could be monitored although they were not at a hospital. In its work, the system is using a microcontroller and smartphone that are connected with the MQTT protocol to help patients. The microcontroller is used for sensing patient heart rate by connecting it with the AD8232 module sensor wich then the signal would be classified to determine the condition of sleep apnea using the KNN classification method. The result of classification by the microcontroller be delivered to the user’s smartphone to be the trigger for alarm, patient’s monitoring system, etc. Research result shows that the MQTT protocol 100% successful to transmit the data with 39.74 ms delay. The patient, patient’s family, and medic smartphone’s apps can monitor and successfully show a notification when sleep apnea’s patient recurring. Accurate of the sensor at sensing heart rate is 91.32% and the accuracy of the classification method is 86.6%. Other than that, the average processing speed from the sensing proses to classification is 1273.85 ms, and the time needed for data arrived at the user’s smartphone is 1312.74 ms.

Our culture abhors the world.Yet Quicksand is swallowing the duellists; the river is threatening the fighter: earth, waters and climate, the mute world, the voiceless things once placed as a decor surrounding the usual spectacles, all those things that never interested anyone, from now on thrust themselves brutally and without warning into our schemes and manoeuvres (Michel Serres, The Natural Contract, p 3). When Michel Serres describes culture's abhorrence of the world in the opening pages of The Natural Contract he draws our attention to the sidelining of nature in histories and theories that have sought to describe Western culture. As Serres argues, cultural histories are quite often built on the debates and struggles of humanity, which are largely held apart from their natural surroundings, as if on a stage, "purified of things" (3). But, as he is at pains to point out, human activity and conflict always take place within a natural milieu, a space of quicksand, swelling rivers, shifting earth, and atmospheric turbulence. Recently, via the potential for vast environmental change, what was once thought of as a staid “nature” has reasserted itself within culture. In this paper I explore how Serres’s positioning of nature can be understood amid new communication systems, which, via the apparent dematerialization of messages, seems to have further removed culture from nature. From here, I focus on a set of artworks that work against this division, reformulating the connection between information, a topic usually considered in relation to media and anthropic communication (and something about which Serres too has a great deal to say), and nature, an entity commonly considered beyond human contrivance. In particular, I explore how information visualisation and sonification has been used to give a new sense of materiality to the atmosphere, repotentialising the air as a natural and informational entity. The Natural Contract argues for the legal legitimacy of nature, a natural contract similar in standing to Rousseau’s social contract. Serres’ss book explores the history and notion of a “legal person”, arguing for a linking of the scientific view of the world and the legal visions of social life, where inert objects and living beings are considered within the same legal framework. As such The Natural Contract does not deal with ecology per-se, but instead focuses on an argument for the inclusion of nature within law (Serres, “A Return” 131). In a drastic reconfiguring of the subject/object relationship, Serres explains how the space that once existed as a backdrop for human endeavour now seems to thrust itself directly into history. "They (natural events) burst in on our culture, which had never formed anything but a local, vague, and cosmetic idea of them: nature" (Serres, The Natural Contract 3). In this movement, nature does not simply take on the role of a new object to be included within a world still dominated by human subjects. Instead, human beings are understood as intertwined with a global system of turbulence that is both manipulated by them and manipulates them. Taking my lead from Serres’s book, in this paper I begin to explore the disconnections and reconnections that have been established between information and the natural environment. While I acknowledge that there is nothing natural about the term “nature” (Harman 251), I use the term to designate an environment constituted by the systematic processes of the collection of entities that are neither human beings nor human crafted artefacts. As the formation of cultural systems becomes demarcated from these natural objects, the scene is set for the development of culturally mediated concepts such as “nature” and “wilderness,” as entities untouched and unspoilt by cultural process (Morton). On one side of the divide the complex of communication systems is situated, on the other is situated “nature”. The restructuring of information flows due to developments in electronic communication has ostensibly removed messages from the medium of nature. Media is now considered within its own ecology (see Fuller; Strate) quite separate from nature, except when it is developed as media content (see Cubitt; Murray; Heumann). A separation between the structures of media ecologies and the structures of natural ecologies has emerged over the history of electronic communication. For instance, since the synoptic media theory of McLuhan it has been generally acknowledged that the shift from script to print, from stone to parchment, and from the printing press to more recent developments such as the radio, telephone, television, and Web2.0, have fundamentally altered the structure and effects of human relationships. However, these developments – “the extensions of man” (McLuhan)— also changed the relationship between society and nature. Changes in communications technology have allowed people to remain dispersed, as ideas, in the form of electric currents or pulses of light travel vast distances and in diverse directions, with communication no longer requiring human movement across geographic space. Technologies such as the telegraph and the radio, with their ability to seemingly dematerialize the media of messages, reformulated the concept of communication into a “quasi-physical connection” across the obstacles of time and space (Clarke, “Communication” 132). Prior to this, the natural world itself was the medium through which information was passed. Rather than messages transmitted via wires, communication was associated with the transport of messages through the world via human movement, with the materiality of the medium measured in the time it took to cover geographic space. The flow of messages followed trade flows (Briggs and Burke 20). Messages moved along trails, on rail, over bridges, down canals, and along shipping channels, arriving at their destination as information. More recently however, information, due to its instantaneous distribution and multiplication across space, seems to have no need for nature as a medium. Nature has become merely a topic for information, as media content, rather than as something that takes part within the information system itself. The above example illustrates a separation between information exchange and the natural environment brought about by a set of technological developments. As Serres points out, the word “media” is etymologically related to the word “milieu”. Hence, a theory of media should be always related to an understanding of the environment (Crocker). But humans no longer need to physically move through the natural world to communicate, ideas can move freely from region to region, from air-conditioned room to air-conditioned room, relatively unimpeded by natural forces or geographic distance. For a long time now, information exchange has not necessitated human movement through the natural environment and this has consequences for how the formation of culture and its location in (or dislocation from) the natural world is viewed. A number of artists have begun questioning the separation between media and nature, particularly concerning the materiality of air, and using information to provide new points of contact between media and the atmosphere (for a discussion of the history of ecoart see Wallen). In Eclipse (2009) (fig. 1) for instance, an internet based work undertaken by the collective EcoArtTech, environmental sensing technology and online media is used experimentally to visualize air pollution. EcoArtTech is made up of the artist duo Cary Peppermint and Leila Nadir and since 2005 they have been inquiring into the relationship between digital technology and the natural environment, particularly regarding concepts such as “wilderness”. In Eclipse, EcoArtTech garner photographs of American national parks from social media and photo sharing sites. Air quality data gathered from the nearest capital city is then inputted into an algorithm that visibly distorts the image based on the levels of particle pollution detected in the atmosphere. The photographs that circulate on photo sharing sites such as Flickr—photographs that are usually rather banal in their adherence to a history of wilderness photography—are augmented by the environmental pollution circulating in nearby capital cities. Figure 1: EcoArtTech, Eclipse (detail of screenshot), 2009 (Internet-based work available at:http://turbulence.org/Works/eclipse/) The digital is often associated with the clean transmission of information, as packets of data move from a server, over fibre optic cables, to be unpacked and re-presented on a computer's screen. Likewise, the photographs displayed in Eclipse are quite often of an unspoilt nature, containing no errors in their exposure or focus (most probably because these wilderness photographs were taken with digital cameras). As the photographs are overlaid with information garnered from air quality levels, the “unspoilt” photograph is directly related to pollution in the natural environment. In Eclipse the background noise of “wilderness,” the pollution in the air, is reframed as foreground. “We breathe background noise…Background noise is the ground of our perception, absolutely uninterrupted, it is our perennial sustenance, the element of the software of all our logic” (Serres, Genesis 7). Noise is activated in Eclipse in a similar way to Serres’s description, as an indication of the wider milieu in which communication takes place (Crocker). Noise links the photograph and its transmission not only to the medium of the internet and the glitches that arise as information is circulated, but also to the air in the originally photographed location. In addition to noise, there are parallels between the original photographs of nature gleaned from photo sharing sites and Serres’s concept of a history that somehow stands itself apart from the effects of ongoing environmental processes. By compartmentalising the natural and cultural worlds, both the historiography that Serres argues against and the wilderness photograph produces a concept of nature that is somehow outside, behind, or above human activities and the associated matter of noise. Eclipse, by altering photographs using real-time data, puts the still image into contact with the processes and informational outputs of nature. Air quality sensors detect pollution in the atmosphere and code these atmospheric processes into computer readable information. The photograph is no longer static but is now open to continual recreation and degeneration, dependent on the coded value of the atmosphere in a given location. A similar materiality is given to air in a public work undertaken by Preemptive Media, titled Areas Immediate Reading (AIR) (fig. 2). In this project, Preemptive Media, made up of Beatriz da Costa, Jamie Schulte and Brooke Singer, equip participants with instruments for measuring air quality as they walked around New York City. The devices monitor the carbon monoxide (CO), nitrogen oxides (NOx) or ground level ozone (O3) levels that are being breathed in by the carrier. As Michael Dieter has pointed out in his reading of the work, the application of sensing technology by Preemptive Media is in distinct contrast to the conventional application of air quality monitoring, which usually takes the form of extremely high resolution located devices spread over great distances. These larger air monitoring networks tend to present the value garnered from a large expanse of the atmosphere that covers individual cities or states. The AIR project, in contrast, by using small mobile sensors, attempts to put people in informational contact with the air that they are breathing in their local and immediate time and place, and allows them to monitor the small parcels of atmosphere that surround other users in other locations (Dieter). It thus presents many small and mobile spheres of atmosphere, inhabited by individuals as they move through the city. In AIR we see the experimental application of an already developed technology in order to put people on the street in contact with the atmospheres that they are moving through. It gives a new informational form to the “vast but invisible ocean of air that surrounds us and permeates us” (Ihde 3), which in this case is given voice by a technological apparatus that converts the air into information. The atmosphere as information becomes less of a vague background and more of a measurable entity that ingresses into the lives and movements of human users. The air is conditioned by information; the turbulent and noisy atmosphere has been converted via technology into readable information (Connor 186-88). Figure 2: Preemptive Media, Areas Immediate Reading (AIR) (close up of device), 2011 Throughout his career Serres has developed a philosophy of information and communication that may help us to reframe the relationship between the natural and cultural worlds (see Brown). Conventionally, the natural world is understood as made up of energy and matter, with exchanges of energy and the flows of biomass through food webs binding ecosystems together (DeLanda 120-1). However, the tendencies and structures of natural systems, like cultural systems, are also dependent on the communication of information. It is here that Serres provides us with a way to view natural and cultural systems as connected by a flow of energy and information. He points out that in the wake of Claude Shannon’s famous Mathematical Theory of Communication it has been possible to consider the relationship between information and thermodynamics, at least in Shannon’s explanation of noise as entropy (Serres, Hermes74). For Serres, an ecosystem can be conceptualised as an informational and energetic system: “it receives, stores, exchanges, and gives off both energy and information in all forms, from the light of the sun to the flow of matter which passes through it (food, oxygen, heat, signals)” (Serres, Hermes 74). Just as we are related to the natural world based on flows of energy— as sunlight is converted into energy by plants, which we in turn convert into food— we are also bound together by flows of information. The task is to find new ways to sense this information, to actualise the information, and imagine nature as more than a welter of data and the air as more than background. If we think of information in broad ranging terms as “coded values of the output of a process” (Losee 254), then we see that information and the environment—as a setting that is produced by continual and energetic processes—are in constant contact. After all, humans sense information from the environment all the time; we constantly decode the coded values of environmental processes transmitted via the atmosphere. I smell a flower, I hear bird songs, and I see the red glow of a sunset. The process of the singing bird is coded as vibrations of air particles that knock against my ear drum. The flower is coded as molecules in the atmosphere enter my nose and bind to cilia. The red glow is coded as wavelengths from the sun are dispersed in the Earth’s atmosphere and arrive at my eye. Information, of course, does not actually exist as information until some observing system constructs it (Clarke, “Information” 157-159). This observing system as we see the sunset, hear the birds, or smell the flower involves the atmosphere as a medium, along with our sense organs and cognitive and non-cognitive processes. The molecules in the atmosphere exist independently of our sense of them, but they do not actualise as information until they are operationalised by the observational system. Prior to this, information can be thought of as noise circulating within the atmosphere. Heinz Von Foester, one of the key figures of cybernetics, states “The environment contains no information. The environment is as it is” (Von Foester in Clarke, “Information” 157). Information, in this model, actualises only when something in the world causes a change to the observational system, as a difference that makes a difference (Bateson 448-466). Air expelled from a bird’s lungs and out its beak causes air molecules to vibrate, introducing difference into the atmosphere, which is then picked up by my ear and registered as sound, informing me that a bird is nearby. One bird song is picked up as information amid the swirling noise of nature and a difference in the air makes a difference to the observational system. It may be useful to think of the purpose of information as to control action and that this is necessary “whenever the people concerned, controllers as well as controlled, belong to an organised social group whose collective purpose is to survive and prosper” (Scarrott 262). Information in this sense operates the organisation of groups. Using this definition rooted in cybernetics, we see that information allows groups, which are dependent on certain control structures based on the sending and receiving of messages through media, to thrive and defines the boundaries of these groups. We see this in a flock of birds, for instance, which forms based on the information that one bird garners from the movements of the other birds in proximity. Extrapolating from this, if we are to live included in an ecological system capable of survival, the transmission of information is vital. But the form of the information is also important. To communicate, for example, one entity first needs to recognise that the other is speaking and differentiate this information from the noise in the air. Following Clarke and Von Foester, an observing system needs to be operational. An art project that gives aesthetic form to environmental processes in this vein—and one that is particularly concerned with the co-agentive relation between humans and nature—is Reiko Goto and Tim Collin’s Plein Air (2010) (fig. 3), an element in their ongoing Eden 3 project. In this work a technological apparatus is wired to a tree. This apparatus, which references the box easels most famously used by the Impressionists to paint ‘en plein air’, uses sensing technology to detect the tree’s responses to the varying CO2 levels in the atmosphere. An algorithm then translates this into real time piano compositions. The tree’s biological processes are coded into the voice of a piano and sensed by listeners as aesthetic information. What is at stake in this work is a new understanding of atmospheres as a site for the exchange of information, and an attempt to resituate the interdependence of human and non-human entities within an experimental aesthetic system. As we breathe out carbon dioxide—both through our physiological process of breathing and our cultural processes of polluting—trees breath it in. By translating these biological processes into a musical form, Collins and Gotto’s work signals a movement from a process of atmospheric exchange to a digital process of sensing and coding, the output of which is then transmitted through the atmosphere as sound. It must be mentioned that within this movement from atmospheric gas to atmospheric music we are not listening to the tree alone. We are listening to a much more complex polyphony involving the components of the digital sensing technology, the tree, the gases in the atmosphere, and the biological (breathing) and cultural processes (cars, factories and coal fired power stations) that produce these gases. Figure 3: Reiko Goto and Tim Collins, Plein Air, 2010 As both Don Ihde and Steven Connor have pointed out, the air that we breathe is not neutral. It is, on the contrary, given its significance in technology, sound, and voice. Taking this further, we might understand sensing technology as conditioning the air with information. This type of air conditioning—as information alters the condition of air—occurs as technology picks up, detects, and makes sensible phenomena in the atmosphere. While communication media such as the telegraph and other electronic information distribution systems may have distanced information from nature, the sensing technology experimentally applied by EcoArtTech, Preeemptive Media, and Goto and Collins, may remind us of the materiality of air. These technologies allow us to connect to the atmosphere; they reformulate it, converting it to information, giving new form to the coded processes in nature.AcknowledgmentAll images reproduced with the kind permission of the artists. References Bateson, Gregory. Steps to an Ecology of Mind. Chicago: University of Chicago Press, 1972. Briggs, Asa, and Peter Burke. A Social History of the Media: From Gutenberg to the Internet. Maden: Polity Press, 2009. Brown, Steve. “Michel Serres: Science, Translation and the Logic of the Parasite.” Theory, Culture and Society 19.1 (2002): 1-27. Clarke, Bruce. “Communication.” Critical Terms for Media Studies. Eds. Mark B. N. Hansen and W. J. T. Mitchell. Chicago: University of Chicago Press, 2010. 131-45 -----. “Information.” Critical Terms for Media Studies. Eds. Mark B. N. Hansen and W. J. T. Mitchell. Chicago: University of Chicago Press, 2010. 157-71 Crocker, Stephen. “Noise and Exceptions: Pure Mediality in Serres and Agamben.” CTheory: 1000 Days of Theory. (2007). 7 June 2012 ‹http://www.ctheory.net/articles.aspx?id=574› Connor, Stephen. The Matter of Air: Science and the Art of the Etheral. London: Reaktion, 2010. Cubitt, Sean. EcoMedia. Amsterdam and New York: Rodopi, 2005 Deiter, Michael. “Processes, Issues, AIR: Toward Reticular Politics.” Australian Humanities Review 46 (2009). 9 June 2012 ‹http://www.australianhumanitiesreview.org/archive/Issue-May-2009/dieter.htm› DeLanda, Manuel. Intensive Science and Virtual Philosophy. London and New York: Continuum, 2002. Fuller, Matthew. Media Ecologies: Materialist Energies in Art and Technoculture. Cambridge, MA: MIT Press, 2005 Harman, Graham. Guerilla Metaphysics. Illinois: Open Court, 2005. Ihde, Don. Listening and Voice: Phenomenologies of Sound. Albany: State University of New York, 2007. Innis, Harold. Empire and Communication. Toronto: Voyageur Classics, 1950/2007. Losee, Robert M. “A Discipline Independent Definition of Information.” Journal of the American Society for Information Science 48.3 (1997): 254–69. McLuhan, Marshall. Understanding Media: The Extensions of Man. London: Sphere Books, 1964/1967. Morton, Timothy. Ecology Without Nature: Rethinking Environmental Aesthetics. Cambridge: Harvard University Press, 2007. Murray, Robin, and Heumann, Joseph. Ecology and Popular Film: Cinema on the Edge. Albany: State University of New York, 2009 Scarrott, G.C. “The Nature of Information.” The Computer Journal 32.3 (1989): 261-66 Serres, Michel. Hermes: Literature, Science Philosophy. Baltimore: The John Hopkins Press, 1982. -----. The Natural Contract. Trans. Elizabeth MacArthur and William Paulson. Ann Arbor: The University of Michigan Press, 1992/1995. -----. Genesis. Trans. Genevieve James and James Nielson. Ann Arbor: The University of Michigan Press, 1982/1995. -----. “A Return to the Natural Contract.” Making Peace with the Earth. Ed. Jerome Binde. Oxford: UNESCO and Berghahn Books, 2007. Strate, Lance. Echoes and Reflections: On Media Ecology as a Field of Study. New York: Hampton Press, 2006 Wallen, Ruth. “Ecological Art: A Call for Intervention in a Time of Crisis.” Leonardo 45.3 (2012): 234-42.

Percy was a put upon pig. Everywhere he went, others pointed and stared. It was never Percy’s intention to be the focus of gossip and innuendo, but it seemed that from the moment he was born, other animals were destined to imbue him with all sorts of various—and often competing—meanings. Percy had asked for none of it. He thought of life as a rather simple affair. What made it complex and often baffling had more to do with what his farmyard friends projected onto him rather than anything that Percy would describe as pig related. As such, Percy had decided early on in life, that he would have no truck with superstition of any kind. The horses would grimace as he walked by; the cows would shake their heads and smile as if … well, Percy could never work out what the ‘as if’ stood in for. It obviously, though, had something to do with long, long ago. Recently, Percy had begun thinking about leaving the farm. This was not a decision to be taken lightly; in fact, it required a great deal of thought and careful planning: mulling over possible outcomes, unforeseen dangers and bends in the road. All clichés of course, but so many elements of any journey are. It was in the setting off, Percy reasoned, that the clichéd nature of any journey ended, and the individual narrative began. Percy’s one friend in the farmyard was Ian the carpet snake, and like Percy, he was unpopular with the other animals. Ian was something of a philosopher and Percy enjoyed their occasional conversations, particularly when things were going poorly for him with the other animals. Which was generally often and generally for reasons that had to do with ancient history rather than any particular matter at hand. “I think that it’s my body that’s the problem”, Percy sighed to Ian as he trotted into the barn. Ian was never quick to respond, reluctant as he was to withdraw from whatever band of sunlight he had managed to slither into. “And what problem is that little pig”, Ian demurred, unable to open his eyes just yet. “Oh well, the same problem as ever I expect”, Percy replied, obviously troubled by his relationships with the other animals in the farmyard. “They’ve been at it again have they?” Ian asked. “The thing is they’re never not at it”, Percy said grumpily. “And I’m sick of trying to work out why it is that everyone has such problems with me”. “Perhaps if you weren’t the only pig in the farmyard …” “But that’s just it, I am the only pig in the farmyard and it’s becoming intolerable. I have no understanding as to why, for the horses, I am an utter disgrace: to the cows, I’m something to pity; the birds see me as an object of ridicule and the chickens … are so arrogant toward me. Chickens! For goodness sake!” “And how is all this related to your body?” Ian asked. “Well,” Percy began, “I can’t help but think I’m somehow flawed. It’s as if my body is a joke of some kind. And it’s a joke that everyone else seems to understand but me. And no one, and I do mean no one, is prepared to tell me the joke to my face. If only I could understand why they feel so strongly about my very presence I might be able to argue my case, assure them that I am somehow different to the pigs they have in their minds”. “Mmm”, Ian muttered as he slithered into a coil and out of his sunlight. This was always the moment of commitment with Ian; the moment that signified a conversation was becoming interesting to the point where he might be encouraged to say something deep and wise; profound even. “Well, they do have a point, Percy”, Ian said. “You are enormously fat, your legs are very short, and your tail curls in disgrace at the size of your behind”. “But that’s just who I am”, squealed Percy in despair. “I can’t help the form my body takes”. Percy was close to tears, his frustration beginning to overwhelm him. “Do not cry or I will not talk to you”, Ian demanded, suddenly forceful. “Oh not you too. Can’t you see I’m distressed? My body”, Percy began, “is constantly hungry. It gives me no relief and my legs … can’t you see they have to be this way in order to support my frame? Being short means my legs are very powerful, they can move me about at more than a fair clip. It’s not right that the horses belittle me. It’s as if all the other animals think I’ve somehow asked to be born this way. As if … no one can see my good points”. “And tell me, Percy”, Ian asked kindly, “what are your good points?” “Well”, Percy replied, “I’m not fussy. I’m very pragmatic. I’m not a dreamer like the cows, or vain like the horses. Nor am I unable to commit like the birds. I have a great capacity to enlighten others as to the possibilities of pleasure and”, Percy continued, a little less sure, “I am loyal and kind”. “Mmm”, Ian demurred once more, “and yet the others are still unkind to you”. “The grasshoppers say that it’s a hangover from the dark ages; that no one actually remembers why it is they should hate me … it’s just that everyone’s sure that is what they’re supposed to do”. “Perhaps,” began Ian, “If you ate a little less?” “But you don’t understand either”, Percy cried. “You’re meant to be my friend, Ian. My one and only friend and yet you criticise me just like they do. As if … as if, my very pig-ness offends you”. “Well I do know how you feel if that is any consolation, Percy. Trust me when I say that my fan club are not people you want to hang out with. Honestly, snake lovers are troubled folk. They simple don’t understand a snake’s desire to be left alone”. “Well I don’t want to be left alone. I want to belong!” shouted Percy. So loud did Percy shout, that the horses standing outside the barn overheard him. And the idea of Percy wanting to belong made them laugh and neigh so loudly that the noise threatened to bring the humans over. Which was never a good idea. Except at feeding time. “Oh, Percy”, Ian sighed, as the horses cantered off shaking their manes in the breeze. “You can’t escape your identity. You think I want to be a carpet snake? Well, I don’t. I want to be an eagle. I’d do anything to be an eagle but that’s just not going to happen. One has to accept ones fate. And unfortunately for you, what being a pig means in this particular moment, is … well”, Ian said rationally, “rather a sad thing. But I will say this, being a pig is better than being a rat. Rats are foul and nasty creatures and you will not find anyone to disagree”. “Except perhaps a rat”, Percy exclaimed. “Oh, they know what foul creatures they are alright”, Ian corrected Percy. “But only because everyone thinks poorly of them”, Percy implored. “Such reasons exist for good … reason”, Ian stated. “Well I’m sure that the reason there are so many rats is because they know they have to stick together. They know the world is against them through no fault of their own”. “For goodness sake, Percy … our identities are put upon us all. Depending upon who our parents are, what time and place we are born into. Tell me this … if you were born a hundred years ago in a different country, do you think you would be the same pig? Do you think you would even speak the same language?” “Well … I don’t know. I’m sure I would have the same pig qualities”. “Indeed. But those qualities belong to your body, to your pig-ness rather than to who Percy is”. “But who Percy is … is constantly put-upon. Constantly manufactured by the other animals. It’s as if my fate was already decided when I was born; as if, just being born a pig was somehow wrong; somehow a disgraceful, offensive thing”. “Exactly”, Ian agreed enthusiastically. “Well, it’s not logical. It’s offensive and cruel”, Percy replied, suddenly agitated. “No one … not one single other animal has ever thought to address me as Percy. They simply see me as a pig. And the absolute worst thing about that is, being a pig, is somehow a dreadful thing for each and every other animal in the farmyard. No one thinks highly of pigs. Not even the dreadful fox who despite his cruel nature would never think to eat pork”. “Well … I’m sure if you lost a little weight’, Ian suggested. “Oh, you’re no help at all”, Percy exclaimed, suddenly angry. “Well I’m not going to take it anymore. I’m going to find a place where I belong. A place where other pigs like me have opportunities and the chance …”, Percy broke off, his courage suddenly deserting him. “The chance for what?” Ian enquired rather cynically. “It doesn’t matter”, Percy replied. “Oh, I think it does” Ian added. “You do, after all, need to know the reason for setting off”. “The reason I’m setting off is because I’m tired of being the only pig; the only animal in the barn who is put-upon is such vicious ways. Why have such dreadful meanings attached themselves to my pig-ness? It’s not fair. I want the chance”, Percy continued. “I want the chance to like my pig-ness, to celebrate my short, fat body and curly tail. I want to find a place where what it means to be a pig is normal rather than something obscure or somehow something to be ridiculed”. “Mmm”, Ian muttered once more as he stretched his long body into the fading band of light. “Good luck and God speed little pig”. “And I’m not a little pig!” Percy exclaimed as he trotted away from Ian, into the reassuring squalor of his pen. Later that night, after all the other animals had fallen asleep, Percy gently opened the latch that kept the gate of his pen closed, walked to the open door of the barn, then disappeared into the bright and starry night. The next morning there was much commotion in the barnyard. The farmer, upon realising that Percy had disappeared, mounted a short though thorough search of the farm. All the other animals were surprised by the farmer’s obvious concern for Percy. It was a concern that the other animals did not share. “Good thing, too”, said the horses amongst each other. “Dreadful little animal”, said the cows. “The neighbourhood is so much cleaner already”, tweetered the birds. “And less smelly”, chimed in the chickens. “Good riddance”, agreed Ian the carpet snack, who was keen to use the occasion to ingratiate himself with the other animals. “You know …” said the oldest and wisest of the cows. “To be born a pig is a punishment from the Gods”. “Yes I know”, said the horse standing next to the cow. “That pig must have killed someone in a past life”. “Yes”, replied the cow, “I never did like the way he tried to be so friendly when he was obviously such a foul creature”. “His very pig-ness disgusted me”, agreed Ian. “Still …”, replied the old cow somewhat suspiciously to Ian. “You did talk with him from time to time”. “It wasn’t that I liked talking to the pig”, corrected Ian. “The pig would simply trot over to where I was … on those dreadful, stumpy, trotting legs and talk and talk and talk. Last time he did so I was asleep; I didn’t wake up until he’d uttered his last sentence”. “You were giggling like a couple of school children yesterday”, corrected the horse. “It wasn’t me…”, Ian replied, attempting to correct the impression that Percy and he were somehow friends. “If you really want to know what happened to the pig last night … I ate him”. The other animals were suddenly dumbfounded. “Liar”, said the old cow. “Yes, liar”, agreed the horse. “It’s not a lie. I always hated that pig and last night …. When everyone else was asleep, I ate the pig”, Ian lied. “You’re a liar, snake. I saw the pig leave early this morning. He opened the latch on the gate to his pen and walked out the barn door without so much as a backwards glance”. Ian looked around at the other animals. Then he slithered away. “That damn snake is just as bad as the pig”, snorted horse. “Worse”, suggested the wise old cow. “You know snakes are compelled to live their lives so close to the ground because the Gods cut off all their legs after one of them lied about what he was capable of”. “Sounds just like that horrible carpet snake”, sneered chicken. “And carpet snakes are called carpet snakes because they came from that dreadful country over the hill that makes the rugs that humans love so much”. “Dreadful, dreadful, slithering snake”, hissed the blackest of the horses. Percy trotted merrily in the bright morning sun, just off to the side of the dirt road. He found that constantly travelling suited him. The whole idea of living in a pen was actually not something he ever wanted to return to. In fact, despite his initial fears when he set off the night before, Percy decided there was very little he liked about his past life. Now that he had his freedom he was determined to keep it; treasure it like the most precious of things. All the animals had decided at a hastily convened meeting that Ian the carpet snake had to be disposed of. Everyone agreed that the farm would be a much friendlier place without both the pig and the snake. “This is our one chance”, horse said very slowly and seriously. “If we don’t grasp it now, we will be forever condemned to share our farm with creatures who none of us like”. “It is a rare opportunity”, mused the cow. “Well it simply has to happen”, said the chicken haughtily. “What we need”, suggested the horse. “Is a plan”. “Yes”, agreed the cow. “Well I already have a plan”, said the bird from up in the tree. “And what’s that?” asked the horse. “Well, because the snake always eats all the mice before any of us birds have a chance to indulge, our plan is to poison a mice and then … just before it dies, place it near the carpet snake so he eats it and in so doing, poisons himself”. The other animals all looked up at the two birds on the branch above their heads. “You’ve really thought about this”, horse said. “Well, of course we have”, fumed the other bird. “Why just yesterday I was swooping down on a little mouse and just as I reached out to grab it in my claws, that evil snake swooped from nowhere and swallowed it whole”. “The snake is very greedy”, mused the cow. “Yes. Nobody likes the snake. Am I right?” asked the horse. “Hear, hear”, everyone agreed. “Right. Put your plan into action then birds and let’s all meet back here in an hour”, commanded the horse. “Good luck”, called the chickens after the birds. Percy couldn’t believe his eyes. He’d heard the noise in the distance as he trotted along in the sun, and then, from out of nowhere, a truck had turned a corner on the winding dirt road and driven straight past him. On board the truck was layer upon layer of pigs; what seemed to Percy like millions of pigs. A whole high-rise city of moving pigs, all squealing and talking in a language that was unfamiliar to him. And as the truck that was filled with pigs rolled past Percy, all he could do was follow it with his eyes. Suddenly Percy was overcome with a sense that his destiny lay onboard that truck; that if only he could manage to get inside the city of moving pigs then he would finally feel that he had found somewhere he could belong. Percy set off at a furious pace, running as fast as he could after the truck. As he got closer and closer, he realised that all the pigs were calling out to him. They seemed to be cheering him on, excited … no, desperate for him to succeed. Percy thought that if he could just run up alongside the driver’s window and somehow get his attention—perhaps by squealing very, very loudly—that the driver would stop the truck and ... The city of pigs continued to squeal desperately at Percy as he raced past their many faces. And Percy squealed back as best he could, desperate to get to the front of the truck and draw the driver’s attention. The truck suddenly slowed to negotiate a bump in the dirt road and Percy found himself in front off the cab. He turned back to face the slowly rolling wheels of the truck and squealed at the top of his voice. The truck’s air brakes hissed noisily and then the whole countryside went quiet for a beat. Percy was breathing very heavily; his face was deep red as he looked desperately up at the windscreen of the cab. Both doors of the truck opened at once and the driver and his passenger hopped to the ground. “Never seen that before”, said the passenger to the driver. “No. Wonder where he came from?” asked the driver. “I think he wants to get on board”, suggested the passenger. Then both the men laughed as they whistled to Percy and slapped at their legs, encouraging the pig to join them at the back of the truck. All the other pigs suddenly squealed as one, desperate to get Percy’s attention. Percy had never heard such a noise; it was both completely familiar though unintelligible. The other pigs seemed somehow overwhelmed by his presence … as if, they’d never seen a pig quite like Percy before. And Percy, as he trotted up the ramp of the truck into the comforting squalor of a million other pigs, squealed happily back at them, finally knowing what it felt like to belong.

Russell Belk,in an amazing 1995 essay on consumption (where 22 of the 38 pages are references, demonstrating hyper-consumption in action), argues that the 1990s heralded a new understanding of consumer behaviour. In the shifting paradigm identified by Belk, the analytical focus of consumer behaviour research became translated from 'Economic/Psychological' to 'Sociological/Anthropological', and from a 'Focus on buying' to a 'Focus on consuming' (61). This made intuitive sense in a world of postmodern marketing (Brown), and it re-enforced an idea that had been put forward by Dallas Smythe that audiences are sold to advertisers . The value of an audience lies in its potential to consume, and Virginia Nightingale subsequently explored this dynamic in her argument that consumption is work: "It is because of the relationship between advertising and television that watching television is work. Watching television is a leisure activity in the pursuit of which viewers are asked to lose themselves, to blur the distinctions between reality and fantasy. They are asked to forget that watching television is also work, to see television advertisements not as a continual reminder of the work of purchasing, but as entertainment. They are asked to believe that what they see on television is what they want to see, specially selected to please them." (33-4) Nightingale had previously argued that consumption in the domestic context was not only work, but quintessentially women'swork: Commercial television is an integral part of the modern shopping world. In this age of image advertising, it is from television that the meanings of brands are learned. If women learned to shop in the nineteenth century, they had to be taught to shop for others in the twentieth. The unpredictable woman of the nineteenth century had to be transformed into predictable, programmable 'Mum' one hundred years later. The branding of food commodities and the establishment of television as an efficient system of brand information assisted a change in the mode of address of the shopping world to women purchasers. In the cut-price world of the 50s and 60s seduction was out and value was in. In a shopping world of comparable brands, Mum has to learn not only the meaning, the lifestyle connotations of branded products from television advertising, but their meanings for the members of the family destined to consume her purchases (33). This way of looking at the world although illuminating begged the question as to an appropriate definition of work. Why did watching television seem so much less like work than, say, typing an article, or working as a waiter? Staying alive breathing, metabolising requires work at some level; what differentiates the 'going to work' side of working: and how does this relate to a consumer society which (as Belk identifies) increasingly involves an emphasis upon consumption rather than production? Greg Hearn, Tom Mandeville and David Anthony estimate that "consumption now accounts for about 60 per cent of GDP ... mass communication, advertising and the consumer economy form a nexus that is centrally implicated in the operation of Western societies" (104). They go on to argue that the "central assertion of postmodern views of consumption is that social identity can be interpreted as a function of consumption" (106). Citing Lunt and Livingstone, Hearn et al. suggest that "fuelled by their ability to modify and process the building blocks of identity (images, visual codes, phrases and ideas), our current mass media, via identity construction, have expanded consumption in advanced industrial societies" (107). Identity construction, however, is a given of existence it is impossible to live without some kind of identity, and impossible to adopt an identity in a vacuum, with no relationship to the social world in which the individual lives. Given that identity-construction is a necessity of existence, and will also necessarily reflect an individual's social practices and their consumption characteristics, can it be seen as 'work'? (And, if not, why not?) One way this problem can be investigated is through changes in work patterns in contemporary societies. Among the most dramatic socio-economic developments of the past two generations has been the changing role of women in the workforce. Some women still in employment are members of the generation which, as recently as the 1960s, were obliged to surrender their jobs upon marriage. Many were subsequently re-employed on a casual basis, but others were unable to resume a career of any sort given that they now had 'family responsibilities' (even if that 'family responsibility' was their spouse alone). The reason behind the compulsory female resignations was the patriarchal view that it was the husband's role to provide financially for his wife. For a married woman to hold a job was akin to double dipping the job was there to support a woman who had no husband to support her; or for a man with a wife (and sometimes other family) to provide for. When women successfully campaigned against this discriminatory practice, and later in favour of equal pay for equal work, the ultimate result was that the real wages of men fell. Two-income families do not earn twice a 'living' wage; they earn a living wage between them. The advent of equal pay for women means that only a small proportion of women (or men) have the choice of making domestic and community-based unwaged labour the focus of their daily life, without the effect of this choice being a much smaller financial engagement in consumer society. The gender dimension to money-earning remains considerable, even in this age of equal opportunity legislation. In particular, the 'wages for housework' campaign has been all but lost over the past thirty years. Further, although it is now unlawful for women to receive less money than their male counterparts for equal work, women's average pay continues to lag significantly behind that of men (WEL). This is one way of demonstrating that traditional women's work tends to be less well paid than men's work. Nursing, teaching and office work all remain low-paid compared with executive occupations, although compulsory post-schooling study requirements might be higher in the female areas. And it is commonplace to note that in traditionally female occupations (like primary school teaching) although males might be out-numbered 5:1 it tends to be a man who gets promoted. (Less a case of the glass ceiling: more a case of the invisible escalator.) In capitalist societies, the original source of monetary wealth lies in power the power to control labour/work for the profit of an individual other than the labourer. This is a hangover from feudal agrarianism, and a precursor to the information age (Bell). In all human society, power confers advantage, including the capacity to direct the work of others. While this was true of the feudal lord, the merchant prince and the early industrialist, it achieved its purest form with the introduction of monetary rewards for labour. Frederic Jameson (77) comments that: "technology may well serve as adequate shorthand to designate that enormous properly human and anti-natural power of dead human labour stored up in our machinery, an alienated power, what Sartre calls the counterfinality of the practico-inert, which turns back on and against us in unrecognizable forms and seems to constitute the massive dystopian horizon of our collective as well as our individual praxis." What Jameson says of technology in general would be equally true of the particular technology of money. Accumulated capital, and its constituent parts of coins, notes, currencies and data sets represents 'dead human labour', in the sense of work expended in the past in the production of goods and services. It is this stored human labour which buys the carrots, or the magazine subscription, and which represents an exchange for the time and energy that would have been required to grow the carrots, or produce the magazine. Similarly, the income paid to the carrot-grower, the journalist, the designer and the advertiser represents to them a distilled recompense for their work. Arguably, the energy that produced the labour for which one is paid is 'dead' energy controlled by another and exchanged for money. At an individual level, the roles played in the personaeof a person earning money, or a person spending money (a common indication of consumption) are very different: with the role of the person earning money much more circumscribed. Joshua Meyrowitz (29-31) spends some time in explaining Goffman's analysis of the roles of the waiter, using metaphors from drama of front/back region/stage: Waiters for example are in a front region when they serve people in a restaurant dining room. In the front region waiters are usually polite and respectful. Their appearance and manner is one of cleanliness and efficiency. They do not enter into the dinner conversations of restaurant patrons. They do not comment on their customers' eating habits or table manners. They rarely, if ever, eat while in the sight of patrons. When waiters step from the dining room into the kitchen, however, they suddenly cross a line between the onstage and backstage areas. In the kitchen waiters are in an area which is hidden from the audience and they share this area with others who perform the same or similar roles vis-a-vis the audience. Here, then, waiters may make remarks to each other about the 'strange behaviour of the people at table seven', they may imitate a customer, or give advice to a 'rookie' on methods of getting big tips. In the kitchen food may be handled and discussed with somewhat less respect than in the dining room, and waiters may 'get out of costume' or sit in a sloppy position with their feet up on a counter... We expect to be treated differently in a restaurant than in a doctor's office. We expect the doctor to appear confident, concerned, patient and professional and slightly superior. We expect a waitress to be efficient, respectful and nonintrusive. And we demand these differences in 'character' even if the waitress is a student earning her way through medical school. This analysis indicates that where behaviour is related to money where a person is paid to fulfil a role; the production of the goods or services the behaviour is more constrained and circumscribed by the expectations of the employer/consumer. The behaviour of people who are paying for a service, whose intention is to consume, is the least constrained. It may be that Kerry Packer has awful table manners, but few restauranteurs would fail to be pleased to see him walking through their door. At the level of the individual producer/consumer in consumer societies, money is seen to exert decisive control in the lives of workers. Is it possible to think of a better, less obviously coercive way to get people into cars, and onto freeways and clocking into the office on such a regular, reliable basis: other than their being paid to do so? American academic Camille Paglia does not think so: "Capitalism, whatever its problems, remains the most efficient economic mechanism yet devised to bring the highest quality of life to the greatest number... Because I have studied the past, I know that, in America and under capitalism, I am the freest woman in history" (Menand 27). Paglia obviously considers herself sufficiently well paid. Since access to money limits access to goods, to some experiences and to travel, money is a potent incentive to behave in a way that is rewarded by society. Even so, not everyone is able to exhibit the work behaviour that social systems are most inclined to reward. The stresses of unemployment lie in its curtailing of options; in its implications for health, housing, leisure, and educational opportunities; and in the fact that the need to get more money monopolises the time of the unemployed. The old adage 'time is money' is only partly true. In some respects the two share an inverse relationship: 'free' time is inversely related to money. For the vast majority of the population, the opportunity to convert work/labour into money significantly limits the time available in which to enjoy consuming the rewards for their labours. When people have 'free' time, it is frequently because the opportunity to earn money by the production of goods and services is absent. Consequently possible consumption activities are also severely limited. There are no hard and fast rules in Jameson's late capitalist society, but the general case might be that we are paid to produce goods, services and information through our controlled work, while consumption is generally constructed as a voluntary activity. It is partly that voluntariness which implicates consumption in identity construction, makes it an expression of individual difference, and renders it potentially pleasurable. Arguably, however, the voluntary nature of consumption together with the impossibility of notconsuming prevents it from being categorised unambiguously as 'work'. The relationship of work to money helps explain why it may be work to watch television, but it's a different kind of work from that performed at the Coles check-out. Identity-construction may be a major consumer project using raw materials provided by the mass media, but it is not work we're paid to do. No-one else is prepared to use their stored labour to recompense us for our everyday work as non-professional television viewers, or for our project of self-individuation as expressed through the production of our personal identity. References Belk, Russell. "Studies in the New Consumer Behaviour." Acknowledging Consumption: A Review of New Studies. Ed. D. Miller. London: Routledge, 1995. 58-95. Bell, Daniel. The Coming of the Post-Industrial Society. Rev. ed. New York: Basic Books, 1999. Brown, Stephen. Postmodern Marketing. London: Routledge, 1995. Goffman, Erving. Frame Analysis: An Essay on the Organisation of Experience. New York: Harper and Row, 1974. Hearn, Greg, Tom Mandeville and David Anthony. The Communication Superhighway: Social and Economic Change in the Digital Age. Sydney: Allen & Unwin, 1997. Jameson, Frederic. "Postmodernism, or the Cultural Logic of Late Capitalism." New Left Review146 (1984): 53-92. Lunt, Peter, and Sonia Livingstone. Mass Consumption and Personal Identity: Everyday Economic Experience. Milton Keynes: Open UP, 1992. Menand, Louis. "Sexual Politics with Snap, Crackle and Pure Paglian Pop." The Australian3 Feb. 1993: 27. Meyrowitz, Joshua. No Sense of Place. New York: Oxford UP, 1995. Nightingale, Virginia. "Women as Audiences." Television and Women's Culture: The Politics of the Popular. Ed. M.-E. Brown. Sydney: Currency Press, 1990. 25-36. Smythe, Dallas. Dependency Road. New Jersey: Ablex, 1981. WEL. 12 Nov. 2001 <http://www.wel.org.au/policy/00pol1.htm>. Links http://www.wlu.ca/~wwwpress/jrls/cjc/BackIssues/17.4/melody.html http://www.onemoreweb.com/soapbox/paglia.html http://www.wel.org.au/policy/00pol1.htm http://www.business.utah.edu/~mktrwb/ http://prelectur.stanford.edu/lecturers/jameson/ Citation reference for this article MLA Style Green, Lelia. "The Work of Consumption: Why Aren't We Paid?" M/C: A Journal of Media and Culture 4.5 (2001). [your date of access] < http://www.media-culture.org.au/0111/Green.xml >. Chicago Style Green, Lelia, "The Work of Consumption: Why Aren't We Paid?" M/C: A Journal of Media and Culture 4, no. 5 (2001), < http://www.media-culture.org.au/0111/Green.xml > ([your date of access]). APA Style Green, Lelia. (2001) The Work of Consumption: Why Aren't We Paid?. M/C: A Journal of Media and Culture 4(5). < http://www.media-culture.org.au/0111/Green.xml > ([your date of access]).

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