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Dopaminergic imaging is an established biomarker for dementia with Lewy bodies, but its diagnostic accuracy at the mild cognitive impairment (MCI) stage remains uncertain.
To provide robust prospective evidence of the diagnostic accuracy of dopaminergic imaging at the MCI stage to either support or refute its inclusion as a biomarker for the diagnosis of MCI with Lewy bodies.
We conducted a prospective diagnostic accuracy study of baseline dopaminergic imaging with [123I]N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)nortropane single-photon emission computerised tomography (123I-FP-CIT SPECT) in 144 patients with MCI. Images were rated as normal or abnormal by a panel of experts with access to striatal binding ratio results. Follow-up consensus diagnosis based on the presence of core features of Lewy body disease was used as the reference standard.
At latest assessment (mean 2 years) 61 patients had probable MCI with Lewy bodies, 26 possible MCI with Lewy bodies and 57 MCI due to Alzheimer's disease. The sensitivity of baseline FP-CIT visual rating for probable MCI with Lewy bodies was 66% (95% CI 52–77%), specificity 88% (76–95%) and accuracy 76% (68–84%), with positive likelihood ratio 5.3.
It is over five times as likely for an abnormal scan to be found in probable MCI with Lewy bodies than MCI due to Alzheimer's disease. Dopaminergic imaging appears to be useful at the MCI stage in cases where Lewy body disease is suspected clinically.
Dopaminergic imaging has high diagnostic accuracy for dementia with Lewy bodies (DLB) at the dementia stage. We report the first investigation of dopaminergic imaging at the prodromal stage.
We recruited 75 patients over 60 with mild cognitive impairment (MCI), 33 with probable MCI with Lewy body disease (MCI-LB), 15 with possible MCI-LB and 27 with MCI with Alzheimer's disease. All underwent detailed clinical, neurological and neuropsychological assessments and FP-CIT [123I-N-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)] dopaminergic imaging. FP-CIT scans were blindly rated by a consensus panel and classified as normal or abnormal.
The sensitivity of visually rated FP-CIT imaging to detect combined possible or probable MCI-LB was 54.2% [95% confidence interval (CI) 39.2–68.6], with a specificity of 89.0% (95% CI 70.8–97.6) and a likelihood ratio for MCI-LB of 4.9, indicating that FP-CIT may be a clinically important test in MCI where any characteristic symptoms of Lewy body (LB) disease are present. The sensitivity in probable MCI-LB was 61.0% (95% CI 42.5–77.4) and in possible MCI-LB was 40.0% (95% CI 16.4–67.7).
Dopaminergic imaging had high specificity at the pre-dementia stage and gave a clinically important increase in diagnostic confidence and so should be considered in all patients with MCI who have any of the diagnostic symptoms of DLB. As expected, the sensitivity was lower in MCI-LB than in established DLB, although over 50% still had an abnormal scan. Accurate diagnosis of LB disease is important to enable early optimal treatment for LB symptoms.
The accurate clinical characterisation of mild cognitive impairment (MCI) is becoming increasingly important. The aim of this study was to compare the neuropsychiatric symptoms and cognitive profile of MCI with Lewy bodies (MCI-LB) with Alzheimer's disease MCI (MCI-AD).
Participants were ⩾60 years old with MCI. Each had a thorough clinical and neuropsychological assessment and 2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl)-nortropane single photon emission computed tomography FP-CIT SPECT). MCI-LB was diagnosed if two or more diagnostic features of dementia with Lewy bodies were present (visual hallucinations, cognitive fluctuations, motor parkinsonism, rapid eye movement sleep behaviour disorder or positive FP-CIT SPECT). A Lewy body Neuropsychiatric Supportive Symptom Count (LBNSSC) was calculated based on the presence or absence of the supportive neuropsychiatric symptoms defined by the 2017 DLB diagnostic criteria: non-visual hallucinations, delusions, anxiety, depression and apathy.
MCI-LB (n = 41) had a higher LBNSSC than MCI-AD (n = 24; 1.8 ± 1.1 v. 0.7 ± 0.9, p = 0.001). 67% of MCI-LB had two or more of those symptoms, compared with 16% of MCI-AD (Likelihood ratio = 4.2, p < 0.001). MCI-LB subjects scored lower on tests of attention, visuospatial function and verbal fluency. However, cognitive test scores alone did not accurately differentiate MCI-LB from MCI-AD.
MCI-LB is associated with neuropsychiatric symptoms and a cognitive profile similar to established DLB. This supports the concept of identifying MCI-LB based on the presence of core diagnostic features of DLB and abnormal FP-CIT SPECT imaging. The presence of supportive neuropsychiatric clinical features identified in the 2017 DLB diagnostic criteria was helpful in differentiating between MCI-LB and MCI-AD.
This chapter introduces students to the range of theoretical perspectives and issues that have animated the study of international relations through the years. First, it explains why theoretical reflection is indispensable to explaining and understanding international relations. Second, it addresses unavoidable ontological and epistemological issues in the quest for theoretical understanding. Third, it traces the growth of mainstream international relations theory. Finally, it analyses the rise of diverse critical approaches to the study of international relations.
The necessity of theory
Attitudes toward ‘theory’ vary among students of International Relations (IR). Some are wary of it, some are frightened of it and some are hostile to it. Theory, it is often proclaimed, is too difficult, too abstract or irrelevant to the real world. Thankfully, these attitudes are changing as IR students in the twenty-first century embrace the theoretical challenges of IR and become aware of sophisticated debates concerning the role of theory in understanding and explaining the real world of which they speak of and in which they live. These debates illustrate that theorising is not something one can choose to avoid; rather, in the process of giving meaning to the things, people, events and controversies in the world, we are engaged in a theoretical process – explicitly or otherwise.
In particular, we cannot simply observe the everyday world of international relations without giving theoretical meaning to what we are seeing. And in this process of observation, we might well bestow different meanings on the same event, as we theorise these ‘real-world’ things in different ways. For example, when we see governments in the United States, the United Kingdom or Australia ramping up their political and strategic responses to Russian ‘expansionist’ inclinations in Eastern Europe and/or similarly perceived Chinese activities in the South China Sea, how are we to make meaningful judgements of these actions? Is this a prudent and justifiable strategy in the face of an otherwise growing threat to Western global interests, or a series of shallow and short-sighted responses to historical and geostrategic complexities likely to enhance anti-Western sentiments and accelerate the very attitudes and behaviours they seek to deter?
This textbook is designed specifically for students studying introductory international relations (IR) courses. Like any good textbook, it aims to introduce students to the study of IR by laying out its chief theories, main actors and institutions, and leading issues in a manner that both excites interest and lucidly explains topics for students with no previous background in IR. Carving up the topics of a complex, dynamic, growing discipline like IR is no easy task. Decisions inevitably must be made about which topics to include and which to exclude. The topics chosen no doubt reflect but one particular perspective of the discipline's present make-up – one account of what is important for students to learn and what is not. Since there is no single correct way to present the material to undergraduate students, there is always a degree of arbitrariness involved in topic selection, and we do not pretend otherwise. However, we believe that the structure adopted here, developed and adapted over many combined years of teaching undergraduate introductory IR courses, offers one useful way into the wide range of fascinating topics that fall under the heading ‘international relations’.
Once again we have revised and updated chapters from the previous edition, but we have also added new chapters and a new part. The textbook is now divided into four parts: Part I on theories of IR; Part II on international history; Part III on what we term the ‘traditional agenda’ of IR, which focuses on states, war and law; and Part IV on the ‘new agenda’, which focuses on globalisation and global governance. These are explicated in more detail in the Introduction, but it is worth emphasising that the new agenda does not succeed the traditional agenda in either time or intellectual resourcefulness. The distinction between traditional and new agendas is a heuristic device meant to remind students that the discipline has evolved and changed, and to encourage reflection on the discipline's historical character. Quite often, textbooks imply that our present conception of the discipline represents something like the end-point in the discipline's ineluctable progression from primitive origins to full development. This conceit is easy to succumb to in the absence of historical-mindedness.
An Introduction to International Relations is a comprehensive introduction to the history,theories, developments and debates that shape the dynamic discipline of international relations and contemporary world politics. Bringing together an expert author team comprising leading academics from Australia and around the world, it allows readers to explore the discipline from both Australian and global perspectives. Known for its clear, easy-to-read style and relevant, real-world examples, the text has been fully updated and revised to reflect current research and the changing global political climate. This edition features extensive new material on: international history from World War I to World War II; international law; the globalisation of international society; and terrorism. A companion website for instructors offers additional case studies, critical thinking questions and links to relevant video and web materials that bring international relations theory to life.
Jim George, Senior Lecturer in International Relations in the School of Politics and International Relations at the Australian National University,
Richard Devetak, Associate Professor in International Relations in the School of Political Science and International Studies at the University of Queensland,
Martin Weber, Senior Lecturer in the School of Political Science and International Studies at the University of Queensland
This chapter introduces students to the rich and controversial legacy of Marxism and one of its major offshoots in the twentieth century, critical theory. The chapter is presented in two parts. The first touches on the historical and intellectual context that ‘created’ Marxism; Marx's notion of historical materialism and the issue of how Marx's ideas have been received in IR. The second part concentrates on the two strands of critical theory that have emerged within IR: one derived from the so-called Frankfurt School and the other from Italian thinker Antonio Gramsci.
Historical and intellectual context: Marx and the critique of capitalism
During the nineteenth century, European societies underwent dramatic and sometimes traumatic changes internally while expanding their colonial rule to almost every corner of the world. Importantly, this expansion of European imperialism and the global consolidation of what is often referred to as the ‘Westphalian states-system’ occurred simultaneously with the comprehensive shift to industrialised production (known as the Industrial Revolution), significant changes in the ownership and control of property and large-scale population transfers, both internally and externally towards parts of the colonised world. By the nineteenth century economic affairs were also changing significantly, with the gradual demise of mercantilism and the rise of capitalism. Victorian Britain (England, specifically) had emerged as the hotbed of these developments, with its extraordinary innovations in industrial production and technology, and in the capitalist production process. It also provided many of the conceptual principles for understanding and legitimising the socio-economic transformations inaugurated by capitalism.
At the intellectuall core of this major historical transformation were philosophers such as Adam Smith (1723–90) in the eighteenth century and David Ricardo (1772– 1823) in the nineteenth century, who helped develop what became known as the liberal ‘political economy’. An outgrowth of moral philosophy, this field of inquiry was concerned primarily with the political and economic conditions of social change. It also became the basis for the discipline of (neoclassical) economics.
The new political economists advanced more stringent conceptions of ‘efficiency’ under capitalism. Arguing against the accumulated wealth and land ownership of the traditional aristocracy, they insisted wealth must be circulated and invested across the whole society. In this regard, they were advocates for an ‘entrepreneurial’ shift from subsistence economies to industrial production, and for social progress guided by scientific reason.