Normal flow velocities and Resistance Index in orbital vessels [15, 31, 32].
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
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Public diplomacy is a concept that has come into sharp focus in academic debate. Recent events, such as the interference in the 2016 US election have drawn attention to the use of public diplomacy to influence the outcomes of the democratic process. The notion that a foreign power can infiltrate social media and internet-based communications in order to impose its own agenda on another population rightly causes concern. This occurrence highlights the ease with which governments can interact with the public of a foreign country in the cyber age. It is this concept, a government conducting diplomacy with a foreign public, rather than through the more traditional government to government channels, that has drawn the attention of scholars. Understanding public diplomacy and the ways in which governments can persuade other states to support their interests through gaining favorable public opinion will provide great insights into the functioning of modern diplomacy. One needs to be aware, however, that the concept of public diplomacy, while relatively new in the academic nomenclature is neither a new activity and nor is it born out of the cyber age. Long before the internet, states were interacting with foreign societies through channels with the public and trying to persuade them to support policies that worked in their favor.
China is one of the commonly studied states in the public diplomacy literature. With China’s rise in recent decades and its move back into the global community, it has become the focus of scholarly attention on many fronts. In an attempt to understand the rise of China and how it is being achieved, the use of public diplomacy by the Chinese government comes under scrutiny. This is due in part to the development of Joseph Nye’s theory of soft power and his work in relation to Sino-US power relations in the hard and soft power realms. China is indeed an interesting case to study in these areas. It is important, though, for that modern use of public diplomacy to be put into a broader and more historical context in order to really enlighten the debate about modern elements of public diplomacy that are of concern. During World War II, China used very effective public diplomacy to win support from the United States for aid and favorable strategy during the war, but it also led to China’s inclusion as one of the few major players in the creation of the post-war international relations infrastructure. In more recent times, China has turned to public diplomacy again as a strategy to gain favorable attitudes towards its foreign policy but with much less effect. Examining the history of China’s public diplomacy in the United States sheds light on some of the concerns facing modern iterations of public diplomacy and cyber technology.
This chapter will define public diplomacy and examine how China uses it now. After commenting on its effectiveness in modern times, a reflection will be made on how China has used it in the past and its effectiveness then will be explored. This will provide a structure for the evaluation of modern public diplomacy and what is different as opposed to just appearing so. The history of Chinese public diplomacy in the United States shows that new technologies and methods of engaging with a foreign public are not necessarily making it more effective. States have been using public diplomacy to gain favor for their foreign policy and interests in other countries for a very long time. Foreign interference in elections is also not a new concept and this has been occurring for centuries. Although new technology and the cyber age appear to make these things more effective, it is not necessarily the case. This is not to say that foreign interference should not be a concern and that the lack of transparency and accountability with which it can occur in the cyber age should not be recognized and addressed. The issues around how best to manage the use of these new technologies and the norms that should be established around public diplomacy need to be explored within the proper context of what is occurring in more recent times in relation to public diplomacy. The way states manage their broader diplomatic relations to protect their own national interest is the key. Strategies to ensure their own interests are protected and supported by the political system and the public need to be developed with a clear understanding of what the real issues and challenges are in order that they can be addressed.
Public diplomacy is the use of media and propaganda in order to influence the public in another country to have a favorable attitude towards your state. According to the Chinese Assistant Foreign Minister in 2004, “[t] he basic goal of public diplomacy is to enhance the exchanges and interaction with the public in order to guide and win the understanding and support of the public for foreign policies” [1]. Other scholars have defined it as “an instrument used by states, associations of states, and some sub-state and non-state actors to understand cultures, attitudes, and behavior; build and manage relationships; and influence thoughts and mobilize actions to advance their interests and values” [2]. In an increasingly interdependent global environment, it is crucial that states have widespread support for their foreign policies in order to be seen as legitimate and credible in the international community. Gaining influence among the public of different states is a way of establishing that broad support.
Propaganda is a closely related concept to public diplomacy. Propaganda is the intentional attempt to sway individuals or groups of people into believing a certain perspective or way of thinking about an event or policy. These two concepts are similar, although as diplomacy is only related to foreign affairs, public diplomacy might be conducted with the use of propaganda, however, not all propaganda will have diplomatic relations as a focus. Since World War II, propaganda as a concept has loaded perception behind it. It has adopted the connotations of evil intent, for which it was used during that conflict. Propaganda in itself is not inherently bad, but it is generally thought of as such in common thinking. Ultimately, though, the aim of propaganda and of public diplomacy can be the same. The objective is to gain support from foreign states for one’s own foreign policy and respect for its national interests.
Public diplomacy is also connected to the concept of “soft power” that was developed by Joseph Nye in the early 1990s. Nye defined soft power as the ability to gain cooperation from another state in achieving one’s desired outcomes. As opposed to using “hard power” of military and economic strength, soft power uses culture, values and shared beliefs and attitudes to persuade, rather than force, another actor in working towards your desired outcomes. The way to do that, according to Nye, is to communicate with other countries and their citizens and engage in cultural exchanges in order to build up the attractiveness of your own values and culture to another society [3]. Or, in other words, conduct public diplomacy. Public diplomacy, then, is a means of creating soft power, while soft power is the actual ability to influence policy.
Public diplomacy as a concept is not new, though the language and nomenclature is relatively so. Although public diplomacy was first being discussed by political scientists at the beginning of the twenty-first century, states have actually been conducting public diplomacy in various forms since the state system and diplomacy was developed. With globalization and the spread of global communication, discourse across state boundaries and between non-state actors, as well as the general public, of different countries became much easier. This phenomenon also facilitated public diplomacy and made communication with the people of a foreign state much easier. Along with Nye’s theory on soft power, these interactions created interest in the study of public diplomacy and it became the subject of scholarship in its own right.
There is, however, still much work to be done on the concept of public diplomacy and its related theories. As technology continues to advance and create new opportunities for means of cross-border interaction, public diplomacy progresses with it. Governments are developing strategies around the use of public diplomacy as recognition grows for the need to conduct diplomacy in this way. By examining the use of public diplomacy in certain contexts, and historically, we can gain a better understanding of the concept and its development over time. We can also put the current debate about public diplomacy, and the use of new technologies to “interfere” in foreign powers’ politics into a clearer perspective.
In China, public diplomacy is a challenging concept. The nature of its political regime means that it is difficult to grasp the idea of a separate public view from a government view. The idea of trying to persuade the general public of something in order to achieve political ends does not sit well with the Communist authoritarian regime. China, over many decades of Communist rule, has focused on obtaining political and economic power and then expected that that will translate into respect from the international community and other great powers. It is only in recent times, as global networks and media have begun to infiltrate international relations that China has begun to explore and give serious effort and resources to the development of public diplomacy [1]. The United States controlled the rhetoric around China’s rising power in the international community and was able to create doubt about China’s peaceful intentions. China was framed as a threat to the Liberal world order that democratic states had worked so hard to establish in the aftermath of the Cold War. Eventually Chinese government officials could see the need to respond to the United States’ narrative and to promote its own perspective through public diplomacy in order to be taken seriously on the global stage [4].
For the purposes of this chapter, the term public diplomacy will be used to describe the concept of government’s interacting and communicating with a foreign power’s citizens in order to influence their attitudes in favor of their interests and policies. Direct public to public diplomacy will not be the focus of the discussion that follows. The means by which communication takes place between the government of one state and the public of another can vary and this chapter will explore the different methods that governments use for this purpose. The motive under study will be the use of a foreign state’s public to gain favor for a country’s foreign policy and interests. This can be achieved either through political pressure brought about by shifting public opinion or by influencing the political process itself through influencing election outcomes or legislators in order to gain support for a change in policy or legislation.
China’s recent record of using public diplomacy is scratchy at best. There are some countries that have developed a favorable attitude toward China’s influence and welcome the benefits, particularly economic benefits, that China’s involvement in their state brings. Latin American, African and some Asian states see China as a positive force in their countries [5]. This is not generally the case in the West. China’s interference in local politics and economics is viewed as a challenge to the recognized order and something to be controlled and limited. Chinese military activities and perceived aggression to build its military prowess has been viewed by many Western states as a rising threat, making them wary of embracing Chinese influence. Although ancient China is often viewed by those in the West as being mysterious and virtuous, under the current Communist regime, China is seen as a threat to the dominant Liberal global order.
The Tiennamen Square incident and the global response to it exposed China’s lack of understanding about how to work with international media and the international community more broadly, and it also created a focus on China as the next threat to the Liberal world order after Russia’s capitulation. In the aftermath of 9/11, when Middle Eastern Islamic Extremists provided a new threat focus, the Chinese government was given an opportunity to shift global thinking about China. Although China’s hard power had grown over the last two decades, little had changed in terms of the international perception of China. The expectation had been that increasing a state’s hard power would eventually and automatically lead to respect and recognition from the international community. This, however, did not occur. In the early twenty-first century, Wen Jiabao began to see the need for a concerted effort towards establishing Chinese soft power and the need for a focus on public diplomacy in order to achieve this. It was recognized that there was a need to gain support from ordinary people for China’s foreign policy in order to establish credibility and legitimacy in the international community more broadly. Branches were created within the Ministry for Foreign Affairs to focus on public and mass diplomacy [6].
A range of activities were undertaken in order to advance China’s public diplomacy. One major program has been the establishment of Confucius Institutes in 64 countries around the world. These institutes have the purpose of promoting the study of Chinese language and culture. The Chinese have come to the view that the biggest barrier to friendly perceptions of China relate to the gap between Western and Chinese language and culture. In order to address this, in 2004 the Chinese government established Hanban (the Confucius Institute Headquarters) to found institutes around the globe to teach foreign citizens about Chinese culture, provide classrooms for language training and to encourage cultural exchanges for foreign students [7]. Confucius Institutes are joint ventures between foreign universities and Chinese partner universities. Chinese universities are ultimately controlled by the Chinese department of education and therefore, are influenced by government. Confucius Institutes can, then, be seen as a channel of communication and interaction between the Chinese government and foreign publics.
The extent to which the Chinese government is able to interact with foreign university students has grown as part of a concerted effort to establish opportunities for cultural exchanges. By engaging at this level, the Chinese government is able to counter the narrative established by Western society about China’s intentions and the threat it poses to Western values. Instead of allowing the West to monopolize the message in global politics, China is now attempting to influence those engaging in the discourse and to have some control over the narrative [1]. That level of control and influence by the government over what in Western societies would be considered to be best left as independent discourse makes societies like the US nervous and suspicious of these channels of engagement.
China has some issues in using the mass media for creating alternative messaging and interacting with foreign publics. Due to the nature of the use of the media in China, and its authoritarian regime, the Chinese government is not shrewd at handling the international media. There have been efforts to expand the reach of Chinese newspapers and Chinese national television into foreign markets to provide some media reach. The extent of the Chinese diaspora can be seen as a great asset for the Chinese government as it allows a broader network of cultural exchange and provides avenues for spreading Chinese media [4, 5, 8]. Chinese public diplomacy, however, is seen by Western societies as being too top down and driven too closely by the Chinese government. This limits the effectiveness of Chinese public diplomacy, particularly in the age of the internet and the ease with which person to person communication can occur even across borders. People to people communication exposes the extent to which the Chinese government controls the message and it is seen as illegitimate and non-authentic.
Wei [9] has conducted a thorough examination of the effectiveness of Chinese public diplomacy. By establishing the objectives of Chinese public diplomacy and evaluating the level of positive feeling towards China in foreign societies, Wei found that in the short term, Chinese public diplomacy is not very effective. The rise in China’s military strength and capability is seen in most Western countries as a threat, and this perception is hard to overcome. Russia was the only state considered in the study that was unconcerned by increasing Chinese military power. Interestingly, Wei’s study found that economic factors do not have as significant a positive influence as one might expect. The economic benefits of interactions with China are clearly outweighed by concern about the threat perception. Wei acknowledges that the study explores the short-term effectiveness of Chinese public diplomacy and that the impact of longer-term strategies, such as the investment in Confucius Institutes, will only be able to be measured in a much longer time frame.
Although the concept of public diplomacy has been named such only in recent years, it has been an activity of governments for decades and indeed centuries. The rise of democracies has seen public diplomacy become an active tool of states to influence public opinion, which in turn leads government policy, in directions that are favorable to their interests. In wartime this can be a particularly useful tool, as it allows for states to influence the strategy, or policies of other states to assist their own wartime aims. Allies are keen to assist each other and cannot afford to create open disharmony or show disunity to the enemy. During World War II, the United States had many Allies and it was a uniquely complex war being fought on many fronts against a coalition of enemy powers. This meant that compromise and careful strategic planning had to govern every decision about where materiel and supplies were sent and what operations would be fought at what time. Amongst the competition within the Allied camp, China was just one voice and the war being fought on Chinese soil was viewed as a backwater battle that lacked the urgency of the war being fought in Europe. Politicians in the US had to manage the expectations of the different Allies as well as that of the American public in terms of what could be done towards achieving victory.
During World War II, China struggled to assert its place among its great power Allies and to force or shame them into providing China support in resisting Japan. Many in the West, including in the United States, were skeptical of China’s proclaimed potential to reach great power status in the post-war world, despite its inclusion as one of the Big Four of the United Nations. In order to sway US public opinion and policy-makers, Chiang Kai-shek sent his Foreign Minister, T.V. Soong, and his wife, Madame Chiang, as personal representatives, to Washington. Stationing these significant figures in the US created political pressure and allowed active public diplomacy. Through their physical presence among the American people and Franklin Roosevelt’s advisors, Soong and Madame Chiang along with other Chinese representatives gained a better sense of public sympathies and fostered an understanding of China among ordinary US citizens. They hoped to turn that sympathy, and the popularity of China’s cause, into financial and military aid and favorable policy decisions. Other factors, such as Japan’s actions and the international situation played a role in the development of the pro-China sentiment, but could not prevent the waning of US support after 1944. Until then, though, the Chinese were quite successful in gaining the sympathy of the US public to back their cause.
After several prominent American officials had visited China between the beginning of 1941 and end of 1942, it had become apparent that Chiang and his close advisors were able to influence those politicians to look favorably on China and its plight. One of the prominent Americans to visit China was Wendell Willkie, who was a Republican politician. In 1940, Willkie had contested the presidential election, opposing Franklin Roosevelt. Although he had been unsuccessful, it was widely believed that he would try again in 1944 [10]. According to the US Ambassador in China at the time, Clarence Gauss, the Chinese government was firmly of the opinion that Willkie would win the election in 1944 and would be the US leader sitting at the peace talks to bring an end to World War II [11]. That being the case, the Chinese wanted to maximize their influence over him. They certainly gained his favor during his visit, as on his return to the US, during a press conference he stated “…one of the difficulties facing me [in remaining objective] is that one falls so much in love with the Chinese people that it is difficult to form a critical and fact-finding judgement” [12]. If Chiang wanted to increase his influence on US officials, gaining favorable public opinion for China would be an excellent means to achieve this.
Willkie’s comment suggested that contact between the Chinese people and Americans could be used to sway them. Although American officials were coming to China and being influenced through that contact, bringing the Chinese people to America might also be an effective means to expand the reach. Generalissimo Chiang and Chinese officials were convinced that being present with the President and his closest advisors was the best way to gain persuasive power over US foreign policy decisions [13, 14]. China began a campaign of influence and engagement with the US public that today would be termed public diplomacy. Officials saw the potential of interacting with the American public directly in order to win favor for its policies and for greater aid and war supplies. The aim was to use the pressure of public opinion to persuade US officials to support China more openly. To do this Chiang decided to send several of his key officials and prominent figures to the United States. He even found an excuse to send his wife, who had a reputation for her beauty and ability to be persuasive and had already successfully won over several US officials using her wiles.
Madame Chiang Kai-shek, who held no responsible position in the government other than being the Generalissimo’s wife, toured the United States from February until April 1943. She worked both in public and behind the scenes. As the President’s personal guest, she stayed at the Roosevelt family estate in Hyde Park, and then in the White House. Her public engagements included addressing each house of Congress, making a speech at Madison Square Garden before a boxing match, and finished with a night of pageantry and speaking at the Hollywood Bowl in Los Angeles [15]. As Chiang Kai-shek remained in China to oversee the war effort and command his troops, Madame Chiang was given access to platforms to address the American people that protocol would not have allowed if he had come to the US with her [16]. Both Chiang Kai-shek and FDR were fond of personalized diplomacy and sidestepping formal diplomatic channels. They believed that more could be achieved with a private conversation than by using the usual diplomatic formalities [17]. Madame Chiang promoted China’s interests through educating the American public about the similarities between the two peoples and by exposing them to herself as the embodiment of modern China. She spoke about democracy, Christianity, justice and cultural plurality, and the plight of China in fighting Japanese oppression, themes that were designed to show that China was not as different or as backward as their long-held stereotypes made out. Madame Chiang was educated in the United States and spoke fluent English. She was the personification of Sino-US relations. From the early days of the war with Japan, Madame Chiang had been writing in the American press and media about China and its causes. Her trip to the US was the opportunity for those familiar with her work to see her in the flesh [16].
The aim of her trip to the United States was to promote China’s interest and encourage public support for US policies that aided those interests. Madame Chiang and other Chinese officials were convinced of the importance of having influential people in Washington, D.C. They felt that being present with the American people was the best way to gain persuasive power over US foreign policy decisions [13]. Her time in the US was a success in terms of achieving those aims. She had enthusiastic support and encouragement for her mission from some prominent Congressmen who even tried to lobby the President and others on her behalf. Despite this, or perhaps because of it, Lauchlin Currie, one of President Roosevelt’s advisors, wrote to John Carter Vincent, the key State Department Officer in charge of relations with China, that officials in the capital were “a bit peeved about her speaking tour” and were sick of hearing the same thing every time she spoke [18]. He noted in March 1943 that “[s]ome people here [in Washington] are still pretty sentimental about China and do a lot of worrying as to whether or not ‘the Chinese’ will be displeased at this or that” [18]. Madame Chiang’s presence in Washington gave her access to the President and to see firsthand the impact of public opinion on his decision-making. This allowed her to find ways to secure promises from him [19]. These promises were often broken later but at significant points they convinced the Chinese that they had American favor. Her presence also added weight to the President’s statements about China made during her time in the US, particularly when those comments were made at a joint press conference [20].
Madame Chiang was the first woman and first Chinese national to address the Joint Houses of Congress, which she did on 18 February, 1943. She opened her speech by saying that “[i]n speaking to Congress I am literally speaking to the American people” [21]. Madame Chiang focused on the discussion of the plight of the Chinese people in fighting the Japanese. American public opinion, government policy and military staff had all begun to adhere to the “Hitler First” policy that put the war in the Pacific in second place to the defeat of the Germans in Europe. Madame’s aim was to shift Congress’s thinking towards giving greater and more urgent support to the Chinese. She espoused the shared values of the people of China and the United States and through retelling stories of her own connections to the US was able to demonstrate the bond between the two countries. Beyond persuading Congress about the need to give greater assistance to China, she also built greater cultural understanding and warm feeling towards the Chinese people.
By addressing Congress directly, she was able to shame them into action on repealing the Chinese Exclusion Act. The exclusion laws had been passed in 1882 and they prevented Chinese immigration to the US for all but the most elite Chinese citizens. The laws had originally been a response to the fear of the Chinese “invasion” of California in the 1880s. Public opinion at that time had been very anti-Chinese. People saw workers from China as stealing their jobs, undermining their claims for work rights and lowering their wages. As the labor movement gained in sophistication they lobbied Congress to restrict the influx of cheap foreign labor [22]. Repeal had been discussed for years but there were always reasons to delay action. Madame Chiang’s visit, however, made further delay impossible. Her performance while presenting her speech to Congress, which moved US representatives and drew long standing ovations and also received a great deal of positive press, was irresistible. She made it near impossible for Congress to deny the pleadings of a state that was an ally and shared so much in common with the US. These moves also led to more favorable public opinion towards supporting China with materiel and supplies as well as strategy. There was pressure on Congress from the American public to do more for China despite what the war strategists and military officials might have thought was in the best interests of the United States and the Allied cause more generally.
Madame’s visit was not welcomed by all. Her level of access and influence (or interference) troubled some in Roosevelt’s administration, and very likely the President himself was annoyed with her insistence, at a time when the conduct of the war was more and more in the hands of the bureaucracy and shaped by international factors. Chinese public diplomacy during the war was not necessarily resulting in policy outcomes that were in the US’s interest. The level of influence that the Chinese were able to gain from interacting and speaking to the American public directly was very effective in many ways. Madame Chiang was a particularly effective public diplomat. She was charming, graceful and elegant. She was also clever and cunning and knew how to manipulate her audience.
There was also evidence that Madame Chiang tried to interfere with the 1944 US presidential election. Republican Wendell Willkie had run against Franklin Roosevelt in the 1940 presidential election and lost. In late 1942, he embarked on a world tour that included a trip to China. During his time in China, Willkie came to know and love the Chinese people through Chiang and his government officials. Chiang Kai-shek and Madame Chiang were taken with Willkie and believed he was sympathetic to China’s plight. Willkie was full of promises of support for Chiang and his regime, particularly in their demand for more munitions and troops [11]. Chiang’s eagerness to befriend Willkie was a result of the fact that he believed Willkie would run for president again in 1944 and win. When it became obvious that the Chiang’s charms had worked on him and the extent of his willingness to promote China’s cause in the United States became apparent, more active steps were taken to assist Willkie’s cause.
According to one newspaper and magazine publisher and media owner, Madame Chiang had made it clear to him that she wanted to support Wendell Willkie to win the 1944 election and that she would spend whatever it took to make that happen. Gardner Cowles reported in his memoirs that he had had a private dinner with Madame Chiang where the conversation had taken place [23]. The US Ambassador to China, Clarence Gauss, reported that the Chiang’s were confident it would be Willkie sitting at the post-war peace table and that this would very much serve China’s interests [11]. At official functions in China, Chinese delegates referred to Mr. Willkie as the next President of the United States and even introduced him as such [24]. It was clear there was deep support for Wendell Willkie and his election campaign and beyond what would be expected in the established norms of diplomatic practice.
Madame Chiang was not the only representative Chiang sent to the US. Chiang had appointed her brother, T.V. Soong, as a special representative to Washington in mid-1940. After Pearl Harbor, he was appointed Chinese Foreign Minister. Chiang had earlier appointed the respected liberal scholar Hu Shi as Ambassador to Washington but his role was to conduct official government to government relations. Madame Chiang and T.V. Soong were clearly sent with a different role in mind. They were to speak to the American people and to engage them in the story and plight of China. Winning the sympathy of the public through a concerted public diplomacy campaign was seen as the most effective way to serve China’s interests.
T.V. remained in Washington to manage this public diplomacy campaign. He soon became friendly with FDR’s closest advisors and Washington insiders, including prominent Americans who formed what later became known as the China Lobby. Being in the US also gave Soong direct access to the American public and he made speeches drawing attention to China’s plight. On October 10, 1942, the anniversary of Sun Yat-sen’s Republican Revolution, Soong told an audience at Carnegie Hall in New York City that China was fighting the way George Washington fought during the American revolution, that China was struggling for its democratic freedom and that it was determined to contribute to the post-war world order as a champion of justice and freedom. He argued that China should, therefore, sit on an executive council of the United Nations Organization as an equal with the US and other Allies [25]. He also wrote articles for various newspapers and journals with similar themes and advocating policies that were sympathetic to China (see, for example, [26]). As with Madame Chiang’s visit, the level of access Soong had to public audiences and to key government officials, and the President himself was only possible because of his presence in the United States and this was clearly the aim of his being there.
Public opinion polls showed dedicated support for the Chinese (or at least the Chinese in China, not for Chinese-Americans or for Chinese immigration). In June 1942 only 9% of respondents to a poll conducted by the Bureau of Intelligence believed that China was doing the least of the Allies to win the war, while 11% believed that the US was doing the least. The same poll found that Americans believed that China was the least likely of the Allies to make a separate peace, even less likely than Britain [27]. The Chinese representatives in the US presented the core message that China had been valiantly struggling in a horrific war against the Japanese and had done so single-handedly for many years before the Allies had entered the conflict. Another key message was that the Chinese were like Americans and they could work together. Evidence of the success of this message can be found in responses to the question “will our Allies cooperate with us after the war?” asked in May 1942. Eighty-three percent of respondents believed that China was the most likely to cooperate [28]. In September 1943 the US Ambassador to China, Clarence Gauss, who was himself skeptical of the Nationalist government, recognized that Chinese “propaganda” in the United States had influenced many Americans to see nothing wrong with China or the Chinese war effort. The public held the US government and misguided policy responsible for anything that went wrong with the war in Asia [29].
By late 1944 there was less optimism about China’s future and its relationship with the US in the post-war world. Officials, the press and the military concluded that political problems in China would complicate the post-war relationship. Japan’s massive Ichigo offensive in Eastern China combined with the resignation of the US Ambassador in China and the recall, at Chiang Kai-shek’s insistence, of the US General commanding Chinese forces, exposed China’s weaknesses. Those shortcomings had been hidden by the propaganda and concerted lobbying of Chinese officials that portrayed China as a strong nation of democratic, hardworking and peace-loving people.
Between 1941 and 1944 Chiang Kai-shek’s personal and official representatives in the United States influenced policy-makers and the American public and used public diplomacy (without it being named as such) to shift US foreign policy towards the assistance of China’s interests. The political pressure generated by the lobbying of US officials and the American public by Chinese representatives in the US influenced policy-makers and the public. Their physical presence in the United States gave these Chinese officials frequent and wide-spread access to both of these key groups. Chiang’s tactic of sending both his wife and brother-in-law to the US did influence some US policy in the short-term. Chiang’s personal position and that of his regime was reinforced for the duration of the war. Although longer term these outcomes may have not lasted, China’s use of public diplomacy during World War II was very effective.
In modern times public diplomacy can be conducted in a much more discreet and far less transparent way. Using the internet to shape public opinion and even influence elections allows foreign powers to engage in diplomacy directly with the people of another country without the knowledge of or by making the government aware of their efforts. The question, though, should be does this make it any more effective? Transparency would create reassurance, but it would not necessarily prevent the efforts of foreign powers to influence the citizens of another country. Surely it is the intent of the behavior that is of greater concern than the means used to influence others.
Jan Melissen in the Oxford Handbook of Modern Diplomacy argues that engaging with foreign publics has become a more necessary condition to conducting successful diplomacy. Public diplomacy is merging with traditional diplomacy to create a “new public diplomacy” [30]. This thinking may be driven more of a transformation of forms of public diplomacy and the new appearance of it than the reality of any seismic shift in diplomatic practice. Madame Chiang in the 1940s was very much aware of the need to address the American people directly and use them as a channel to shift their government’s thinking. Even before the internet and mass cross border communications, the need to gain public favor was recognized and important resources allocated to achieving that end. The Chinese sent several key representatives to the United States for visits and to reside for the duration of the war. They found ways to interact with the American public directly and to use US public opinion to sway Congress and the administration into supporting policies that aided China’s cause.
China’s more recent efforts at public diplomacy have been less effective than these earlier activities. There is merit, then, in exploring what it is that makes China’s public diplomacy less effective. The study conducted by Cao Wei, then, is worthy of investigation. In a study exploring Chinese public diplomacy in six countries, including Russia, Japan, France, Germany, the UK and US, Wei found that very little positive impact on favorable public sentiment toward China. In fact, the growth of Chinese military power caused concern in all of these societies, except Russia, that outweighed any efforts at public diplomacy in these states. Even friendly economic relations did little to assist foreign publics in their receptiveness to Chinese diplomatic charm. Wei found three possible reasons for this. Firstly, there is a bias against China that comes from the difference between the political system and culture of China and Western countries. Secondly, China’s military power is a disadvantage. Few countries are happy about increasing military power of another, apart from very close allies. Third, China’s proficiency at conducting public diplomacy is inadequate [9]. Wei is not alone in this conclusion (though perhaps in the specificity of the reasons why). Other scholars agree with the conclusion that China’s public diplomacy is largely ineffective and that much work needs to be done in terms of both the messaging of that diplomacy and the activities used to spread that message for it to sway Western societies in favor of China’s policies (see, for example, [5, 8]).
If China is using modern methods of public diplomacy and yet being no more effective in their influence, then it is not these modern methods that should be a major focus of concern. The intent, effectiveness and receptibility of the message should be a greater concern. China’s public diplomacy during World War II was very effective in achieving the aims of Chiang Kai-shek’s regime. Admittedly, China was operating under an ostensibly democratic regime. The extent to which China under Chiang was more democratic than the current regime is the subject of a long-standing academic debate that cannot be espoused in detail here. Certainly, though, Chiang and his officials were skilled at presenting the message that his government and the Chinese people were totally committed to democracy, freedom and equality and so shared those values with the people of the United States. Ultimately it was this message, and not so much the methods used to convey them, that allowed Chinese public diplomacy in the 1940s more effective.
Moving beyond influencing public opinion, and even governments, to direct interference in an election can be seen as a breach of diplomatic good faith. Defining the boundaries of legitimate public diplomacy that involves trying to influence policies and people and interference in the outcome of an election poses a challenge to the development of international norms for diplomacy. It is related to the advancement in technology and the rise in new areas of diplomacy, such as cyber diplomacy. As the internet becomes the newest realm of global commons, the international community needs to think more deeply about how to establish norms and regulate behavior to match the capabilities that cyber technologies allow.
Public diplomacy and the norms of international relations suggest that it is improper for one state to sew discord and disharmony in another. The internet and the ability to easily “break into” public discourse in another country have led to increasing concerns in recent times about the ability for a foreign power to do just that. Not only are the methods available to do this seen as making it easier, but it is also possible to do it without detection. The anonymity the internet has allowed for the source of news stories and communication with a foreign public means that there is a lack of accountability for the messages within that communication. Russia’s interference in the 2016 US presidential election has sparked a debate about what should be tolerated as rights to privacy and free speech on the internet and the need to intervene to secure the rights of the state. While most media have rules and restrictions on its ownership, use, and funding, the internet has so far escaped thorough regulation. This is now being reviewed.
There is evidence that the Russians used paid advertisements, clearly targeting specific groups and electorates using metadata gathered from Facebook and other internet social media. Russian sources also created “fake news” and planted stories on the internet that were not true in order to sway voters against voting for Hillary Clinton. The Democratic National Campaign was also hacked into and sensitive information about their campaign strategy and the candidate was accessed. As Baines and Jones point out in their article about the subject, influencing foreign elections is not a new phenomenon, but this was an extraordinary level of interference. The methods used to influence the election also constituted an attempt to undermine democracy altogether rather than just trying to sway the outcome [31]. This intent does pose a threat to society and could qualify as an act of espionage or worse.
It is not just the interference in elections that poses a threat to modern democracies. The ability to sway the legislative branch can have a greater impact on the policies of a country. As laws are made by legislators that are influenced by a broad set of interests, if foreign states are able to add their interests into the mix then favorable policies will follow. There has long been a struggle between Congress and the presidency over who has control for foreign policy [32]. In order to offset some of the advantages that the presidency has with its use of the State Department, Congressmen often visit foreign states or make themselves available for foreign officials to gather information about foreign affairs. This method of gathering information, however, is problematic in that it opens the door for misinformation or propaganda that does not necessarily serve US interests [33]. This well describes the events detailed above in Sino-US relations during World War II, but it also continues to be a vulnerability of the US political system. It is not, however, a new problem arising from the newly formulated concept of public diplomacy or new public diplomacy. If anything, this is an issue that has existed since the founding fathers established the United States.
The use of the internet and digital means to reach a population has increased the potential “threat” of foreign interference but foreign interference of and in itself, like the term propaganda, is not a negative concept. It is the perspective taken about the intent of the interference and the objectives of foreign countries in using their influence that should be the focus of concern. The methods used to conduct public diplomacy have less impact on the effectiveness of influence over a foreign public than the message being sent. The best protection for a state against negative influences that can impinge on its interests is to ensure robust principles and systems exist within its society. An informed and questioning public, an open and transparent media and elected officials who measure the performance of their duties on how well they serve the public interest are all much more important than preventing foreign access to the internet and social media.
This chapter has examined the use of public diplomacy by China across different time periods of history. This examination reveals that public diplomacy, despite being the focus of recent study by a range of scholars, has been a long-practiced activity of states in order to influence other states towards policies and attitudes that are favorable to their interests and aims of foreign policy. In World War II, China very effectively used methods of engagement with the people of the United States, such as personal addresses to audiences, newspaper and magazine articles and public appearances. China was able to gain the sympathy of the American people for its war aims and convinced them of the need for greater support from the US government. Some Chinese officials were even involved in trying to influence the outcome of the 1944 US elections so that a president more sympathetic to China’s plight would be sitting at the peace table at the end of the war. Exploring these events and the means the Chinese used to work towards their objectives sheds light on more recent studies of these topics.
The digital revolution has created an environment where political messages can more easily cross state boundaries and there is greater opportunity for government officials to interact with foreign publics directly. The cyber world, more importantly, provides anonymous access. There is a lack of transparency and accountability in the use of social media and internet news sites to connect with people in a different state. That lack of transparency is a cause for concern. It is the specter of a foreign authoritarian regime being able to undermine the legitimate government in democratic states that keeps government officials awake at night. There is a clear need to work towards greater accountability in the cyber world and to develop regulation and norms around cyber diplomacy. This is a task that is urgent and necessary. Creating a strong and robust regime for the digital world and cyber diplomacy will not, however, create a “safe” political environment free of foreign interference. Not that all foreign interference is inherently negative. The motives and intent behind the interference is the key to its virtue. The best defense against dangerous foreign interference that is targeted to break down democratic principles is to strengthen the democratic model that is in place.
A well informed, educated public that has access to good information, questions what they read and are told, scrutinizes decisions and arguments and has access to a free and open media is a good start towards protecting democratic values and regimes. China’s more recent public diplomacy lacks the effectiveness of its earlier efforts. In World War II, China could claim its support and championing of American values of freedom, equality and democracy. That is no longer true and the American public can determine for itself the values of the Chinese government. The fear brought about by the rise of China’s military power outweighs the messages being sent by Chinese government officials to foreign publics through its diplomacy. There are many other factors at play that determine the effectiveness of China’s influence over the American people and those in the West more generally. The means and methods of the conduct of public diplomacy, then, is not the area for greatest concern. Rather any studies of modern public diplomacy should focus on the intent and objectives of a state’s public diplomacy and how effective the diplomacy is in achieving those aims. There will always be a line to cross from public diplomacy into espionage and damaging another society with diplomacy that should always be the subject of regulation and frameworks to ensure that line is not crossed. In itself, however, gaining access to the public of a different state and trying to influence it towards supporting one’s interests and foreign policy is not something we should work to avoid. We should be careful that the debate about public diplomacy and its utility stays on course for delivering good outcomes for the international community and is not distracted down byways of fear.
Giant cell arteritis (GCA) is a primary (non-necrotizing granulomatous) vasculitis of autoimmune etiology, which especially affects extra cranial medium-sized arteries (branches of the external carotid arteries-ECAs-particularly the superficial temporal arteries-TAs) and sometimes large-sized arteries (aorta and its major branches). It is also recognized as Horton, temporal, or granulomatous arteritis. It causes narrowing of the artery, leading (by wall thickening) to partial (stenosis) or complete obstruction (occlusion) of local arterial blood flow, its clinical manifestations being expressed by signs of local ischemia [1, 2, 3, 4, 5, 6].
\nGCA is the most common form of vasculitis that occurs in adults and in the elderly, being diagnosed over the age of 50’s. Women are two to three times more affected than men. It is well known that the disease can occur in every racial group but is most common in Caucasians, especially people of northern European descent, and others in northern latitudes. [1, 2, 3, 4, 5, 6].
\nAccording to Hunder [7], and Jennette [8] a complete diagnosis of GCA requires the presence of American College of Rheumatology (ACR) classification modified criteria:
age over 50 years at the onset of the disease;
moderate, bitemporal, recently installed headache;
scalp tenderness, abnormal temporal arteries on inspection and palpation (Figure 1), reduced pulse, jaw claudication (pain in the jaw while/after chewing);
blurred vision or permanent visual loss in one or both eyes (since permanent visual loss due to ischemia is frequent, GCA should be considered an ophthalmic emergency requiring immediate management);
systemic symptoms (fatigue, weight loss, fever, pain in the shoulders and hips: polymyalgia rheumatica);
increased inflammatory markers (erythrocyte sedimentation rate greater than 50 mm/h, C reactive protein greater than 1,5 mg/dl);
representative histologic findings in temporal artery biopsy (TAB): mononuclear cell infiltration or granulomatous inflammation of the vessel wall, usually accompanied with multinucleated giant cells (Figure 2).
Giant cell arteritis (GCA) of the left superficial temporal artery (TA) shows a prominent, tender and nodular artery, that is also hypo pulsating on palpation [9].
The histopathological examination of the left superficial temporal artery biopsy (TAB) noted [10]. (A) Thickened vascular wall with inflammatory infiltration of multinucleated giant cells, (B) epithelioid cells and (C) dissolution of the internal elastic lamina (H&E stain).
Several imaging techniques may be suitable in the diagnosis of GCA. [9] Compared to other imaging techniques, US is considered to be the most suitable in the evaluation of GCA patients, therefor it can easily be performed by the clinician (immediately after the general examination of patient), and it is significantly shortening the waiting period until another investigation is performed. [9, 10, 11, 12, 13, 14, 15, 16].
\nUltrasonography (US) is a safe, noninvasive, without radiations, widespread accessible, fast, and low-cost bedside screening technique which has the unique capacity of studying real-time hemodynamics. It presents the ability to evaluate the anatomy of vessel’s wall, identifying equally parietal abnormalities (wall thickening, hypoechoic plaques, clotting, parietal hematoma, dissections) and the external diameter of the artery; it can rule out both stenosis and occlusion. Therefore, the use of US is widespread in neurological clinical practice, mainly in the evaluation of arterial atherosclerotic process but also for monitoring other diseases such as medium/large-vessel vasculitis. [17, 18, 19].
\nOlah noted that for US imaging of extracranial vessels different modes are being used:
\nB-mode (brightness mode)\n
The strength of the echo is recorded as a bright dot, while the location of different gray dots corresponds to the depth of the target. [17]
\nb. The duplex image\n
It associates a B-mode gray-scale image with pulse-wave (PW) Doppler flow velocities measurements.
The B-mode image represents the anatomical localization of the vessels, indicating the zone of interest where a Doppler sample volume should be placed and where the velocities are measured.
The Doppler angle can be measured correctly when the blood is parallel to the direction of the vessel. [17]
\nc. Color Doppler flow imaging\n
Measure mean frequency shift in each sample volume.
It represents color–coded velocity information, which is superimposed as a color flow map on a B-mode image.
In each sample volume, the color reflects the blood flow velocity in a semi quantitative manner, as well as the flow direction relative to the transducer. Blood flowing toward or away from the transducer is shown by different colors (red and blue). Moreover, fast flow is indicated by a lighter hue and slow flow by a deeper one.
The color flow map indicates the position and orientation of the vessels, as well as the site of turbulent flow or stenosis. Since color flow mapping is based on flow velocity measured by PW technology, aliasing occurs if the frequency shift is higher than half of the pulse repetition frequency (PRF). [17]
\nd. Power Doppler mode\n
Uses the signal intensity of the returning Doppler signal instead of frequency shift.
Power (intensity) of the signal is displayed as a color map superimposed on a B-mode image. Since the Doppler power is determined mainly by the volume rather than the velocity of moving blood, power Doppler imaging is free from aliasing artifacts and much more sensitive to detect flow, especially in the low-flow regions. However, it does not contain information about the flow direction or flow velocity. [17]
The advantages of US over other imaging techniques in GCA are represented by its safety, accessibility, tolerability, fast (may take about 15-20 minutes, if it’s conducted by an experienced sonographer) and the more important, its high resolution (a high –frequency probe offers both an axial and a lateral resolution of 0.1 mm) [19, 20, 21, 22, 23, 24, 25, 26, 27]. The smaller the vessel diameter, the more difficult is to appreciate the vessel wall damages, so that, in this case, the most informative US data are based on Doppler spectral evaluation. This is also valid for the assessment of medium to small vessel inflammation such as intracranial vasculitis. Small vessel vasculitis (the ANCA-associated or the immune complex vasculitis) are not a domain of ultrasound. [19].
\nFurthermore, US has a higher sensitivity than TAB, the last one evaluating only a restricted anatomical region in a systemic disease. Using US, we can reveal pathological characteristics in GCA: non-compressible arteries (compression sign), the wall thickening (“halo” sign), stenosis and vessel occlusion. A normal intima-media complex (IMC) of an artery is represented by US as a homogeneous, hypoechoic or anechoic echo structure delineated by two parallel hyperechoic margins. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nThere is imperative to underline the importance of establishing the arteries that should be routinely examined in a patient suspected for GCA and these are: the TAs, and axillary arteries. If US of these arteries does not reveal suggestive lesions, in the presence of a clear patient history and of an obvious clinical examination, other arteries should be examined: other branches of the ECAs (the internal maxillary, the facial, the lingual, the occipital arteries), the vertebral, the subclavian, the common carotid arteries-CCAs, and the internal carotid arteries-ICAs. [9, 19, 21].
\nRegarding the adequate US equipment for the diagnosis of GCA, modern high-resolution linear probes providing Doppler mode should be used, especially for examination of TAs. We should take into consideration that tissue penetration increases with lower frequencies and the resolution of US increases with higher frequencies. Probes that provide frequencies >20 MHz allow the clearly visualization of the normal IMC of TAs probes with frequencies ≥15 MHz are usually used for detection of minor wall thickening. [19, 21].
\nIn 2012, during the Chapel Hill Consensus Conference [19, 28], large vascular vasculitis (LVV) was well-defined as a vasculitis involving the aorta and its major branches, although any size of artery may be affected. This definition does not state that LVV mainly affects large vessels because in many patients, the number of medium and small arteries affected is greater than the number of large arteries involvement. For example, in GCA, only few branches of the ECAs may be affected when there is involvement of numerous small branches extending into the eye and orbit (e.g., central retinal artery, posterior ciliary arteries). [29, 30] Less frequently, the CCA and the ICA are also affected (Figures 3 and 4). [9].
\nLarge vessels GCA; CT-angiography- occlusion of the left CCA, ECA, and ICA [9].
Large vessels GCA, color Doppler ultrasound in transverse view of the right CCA. Hypoechoic wall swelling with right CCA occlusion [9].
As Sturzenegger pointed up, angiography is not able to illustrate the vessel wall, so as to diagnose the inflammation of the large cervical and cervico-brachial vessels (aorta and its supra-aortic branches), the US can be very useful, since it can define alterations of the vessel wall with the use of B-mode imaging, while Doppler spectral flow velocity evaluation can help identify the stenosis or occlusion of the vessel. [19].
\nColor Doppler Duplex sonography (CDDS) is an excellent device used in screening the large vessels involvement. Agreeing with different authors, including Sturzenegger, there are two ultra-sonographic hallmarks of large vessels GCA:
Vessel wall thickening, that typically is homogeneous, circumferential and over long segments (Figures 4 and 5);
Stenosis, typically revealing slickly tapered luminal tightening (hour glass like) [19, 20, 21, 22, 23, 24, 25, 26, 27]
Large vessel GCA, color Doppler ultrasound in longitudinal view of the right CCA with hypoechoic wall swelling [4].
Remarkably in some cases [9], the common carotid and the internal carotid arteries are also involved (large-vessel GCA) (Figures 3, 4, and 5).
\nExtracranial Duplex sonography investigates almost completely the whole length of the common superficial TAs, including the frontal and parietal branches, and founds that inflammation is segmental (intermittent arterial involvement) [19, 20, 21, 22, 23, 24, 25, 26, 27]. The common superficial TA derives from the ECA. It divides into the frontal and parietal ramus in front of the ear. The distal common superficial TA and the rami are localized between the two layers of the temporal fascia, which is like a bright band at ultrasound examination. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nHigh-resolution color Doppler US can illustrate the vessel wall and the lumen of the TAs. One should use linear probes with a minimum gray scale frequency of 8 Mhz. Color frequency should be about 10 Mhz. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nThe pulse repetition frequency (PRF) should be about 2.5 kHz as maximum systolic velocities are rather high (20-100 cm/s). Steering of the color box and the Doppler beam should be maximal as the rami are parallel to the probe. It is important that the color covers the artery lumen exactly. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nThe sonographer should perform at least 50 Duplex ultrasound of the TAs of subjects without GCA to be sure about the appearance of normal TAs before starting to evaluate patients with GCA. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nThe investigation should begin with the TA, using the longitudinal scan. The probe should then be moved along the course of the TA to the parietal ramus. On the way back one should delineate the TA in transverse scans. Using the transverse scan, one can find the frontal ramus, which should then be delineated in both scans (longitudinal and transverse). If the color signal indicates localized aliasing and diastolic flow, one should use the pw-Doppler mode to confirm the presence of stenosis. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nIn 1997 Schmidt et al. proved that the most specific (almost 100% specificity) and sensitive (73% sensitivity) sign for GCA was a concentric hypo-echogenic mural thickening, dubbed “halo”, which the authors interpreted as “vessel wall edema”. [24].
\nOther positive findings for GCA are the presence of occlusion and stenosis. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nIn conclusion, there are three important items in the ultrasound diagnosis of temporal arteritis:
“dark halo” sign – a typically homogeneous, hypoechoic, circumferential wall thickening around the lumen of an inflamed TA - which represents vessel wall edema and a characteristic finding in temporal arteritis/GCA. It is well delineated toward the lumen (Figure 6).
stenosis are documented by blood-flow velocities, which are more than twice the rate recorded in the area of stenosis compared with the area before the stenosis, with wave forms demonstrating turbulence and reduced velocities behind the area of stenosis (Figure 7).
acute occlusions, in which the US image is comparable to that of acute embolism in other vessels, showing hypoechoic material in the former artery lumen with absence of color signals. [19, 20, 21, 22, 23, 24, 25, 26, 27]
Color Doppler ultrasonography (CDUS) of the right TA shows a hypoechoic halo around the lumen in transverse view (arrow). The “halo sign” corresponds to edema of the artery wall. [11].
Longitudinal view of the right TA by color Doppler ultrasonography (CDUS) shows a hypoechoic halo of the TA and the presence of turbulent and weak flow, suggesting the presence of stenosis. The PSV is 1 m/s, that is double compared to the segment without stenosis. [11].
Related ultrasound patterns can be found in other arteries: the facial, the internal maxillary, the lingual, the occipital, the distal subclavian and the axillary arteries.
\nThe best time to perform ultrasound investigation is before initiating the corticosteroid treatment, or in the first 7 days of treatment, since with corticosteroid therapy the” halo” revealed by TAs ultrasound disappears within 2-3 weeks. The wall inflammation, stenosis, or occlusions of the larger arteries (CCA, ICA) remain for months, despite corticosteroid treatment. However, the diagnosis process should not postpone the initiation of therapy. Ultrasound may also detect inflamed TAs in patients with clinically normal TAs. Some patients with the clinical image of polymyalgia rheumatica, but with hidden TAs may be diagnosed using ultrasonography. [9, 10, 11, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 27].
\nIn 2010, Arida et al. [26] evaluated a number of studies that examined the sensitivity and specificity of the “halo” sign confirmed by TA ultrasound (US) for GCA diagnosis versus the American College of Rheumatology (ACR) 1990 criteria for the classification of this vasculitis (used as a reference standard). Only 8 studies involving 575 patients, 204 of whom received the final diagnosis of GCA, achieved the technical quality criteria for US. This meta-analysis disclosed a sensitivity of 68% and a specificity of 91% for the unilateral “halo” sign, as well as 43% and 100%, respectively, for the bilateral “halo” sign in TA US for GCA diagnosis when the 1990 ACR criteria are used as the reference standard. The authors established that the halo sign in US is of great utility in diagnosing GCA. [19, 20, 21, 22, 23, 24, 25, 26, 27].
\nIn the case of consistent clinical and sonographic results, temporal arteries biopsy (TAB) does not appear to be useful and justified. [19, 27].
\nSturzenegger affirmed that differential diagnosis with arteriosclerosis is important in patients over 50 years, taking into consideration that GCA with large vessels disease disturbs almost exclusively this category of patients. There are some characteristic features of the arteriosclerotic wall: the thickening usually appears less homogeneous; there are calcified arteriosclerotic plaques ulcers; stenosis extends over shorter segments, they are not concentric, not tapering, and location of lesions differs (e.g., mainly bifurcations). [19].
\nBesides, agreeing to Sturzenegger, differential diagnosis with the other LVV, especially Takayasu arteritis, has to be reflected:
Takayasu arteritis usually affects women below the age of 40 years;
symptoms like tender scalp or polymyalgia syndrome are exceptional;
the involvement of CCA is more frequent in Takayasu arteritis, while the involvement of temporal artery in Takayasu arteritis is not known;
US image of wall thickening (“halo”) is brighter in TA than in GCA probably due to a larger mural edema in GCA which is a more acute disease than TA. Reflected. [19, 20, 21, 22, 23, 24, 25, 26, 27]
Approximately 25% of patients with temporal artery biopsy (TAB) - proven GCA have ophthalmologic complications: usually unilateral visual loss (due to the vasculitic involvement of orbital vessels:
of posterior ciliary arteries (PCAs) - represented by arteritic anterior ischemic optic neuropathies (A-AION), or
of central retinal artery (CRA) - represented by central retinal artery occlusion (CRAO). [31, 32, 33, 34, 35]
Schmidt compared the results of TAs-US examinations with the occurrence of visual ischemic complications (A-AION, CRAO, branch retinal artery occlusion, diplopia, or amaurosis fugax) in 222 consecutive patients with newly diagnosed, active GCA. [21, 22, 23, 24].
\nHowever, findings of TAs US did not correlate with eye complications. [21, 22, 23, 24].
\nThis is the reason why we always have to exam the orbital (retrobulbar) vessels in GCA patients or in patients with unilateral abrupt visual loss [9, 10, 11, 12, 13, 14, 15, 16] (Figure 8A,B).
\nColor Doppler imaging (CDI) of orbital (retro-bulbar) vessels: (A). central retinal artery (CRA); (B). posterior ciliary arteries (PCAs) [15].
The ophthalmic artery (OA) branches in several arteries, including (Table 1):
the central retinal artery (CRA) (Figure 8 A), and
the posterior ciliary arteries (nasal and temporal branches-nPCAs, tPCAs) [28, 31, 32] (Figure 8B), (Table 1). [15, 28, 31, 32]
Parameter | \nOA | \nCRA | \nPCA (temporal) | \nPCA (nasal) | \nSOV (superior ophthalmic vein) | \n
---|---|---|---|---|---|
PSV (cm/s) | \n45,3 ± 10,5 | \n17,3 ± 2,6 | \n13,3 ± 3,5 | \n12,4 ± 3,4 | \n10,2 ± 3,8 | \n
EDV (cm/s) | \n11,8 ± 4,3 | \n6,2 ± 2,7 | \n6,4 ± 1,5 | \n5,8 ± 2,5 | \n4,3 ± 2,4 | \n
RI | \n0,74 ± 0,07 | \n0,63 ± 0,09 | \n0,52 ± 0,10 | \n0,53 ± 0,08 | \n\n |
OA finishes in the a. supra-trohlearis and A. dorsalis nasi.
\nStandard neurovascular ultrasound machines equipped with linear-array transducers emitting 6-12 MHz (up to 15 MHz) are adequate for identifying (by Color Doppler sonography), and measuring (by spectral analysis pulsed Doppler sonography) the blood flow in the orbital vessels: the OA, the CRA and central retinal vein (CRV), PCAs, and the superior ophthalmic vein (SOV). [28, 31, 32].
\nThe CRA, a distal branch of the OA, enters the optic nerve (ON) approximately 1-1.5 cm distal from the bulbus coming from the dorsolateral direction. Parallel to this is the CRV.
\nThe PCAs are located near the optic nerve (ON) (the nasal-nPCA and the temporal-tPCA branches). [28, 31, 32].
\nIf the vessels are difficult to display, the power should be elevated for a short time if the clinical question is important. [28, 31, 32].
\nThe optic nerve head (ONH) consists of (from anterior to posterior):
the surface nerve fiber layer - mostly supplied by the retinal arterioles. The cilioretinal artery, when present, usually supplies the corresponding sector of the surface layer. [36, 37, 38, 39, 40]
the prelaminar region - situated anterior of the lamina cribrosa. It is supplied by centripetal branches from the peripapillary choroid. [36, 37, 38, 39, 40]
the lamina cribrosa region - supplied by centripetal branches from the posterior ciliary arteries (PCAs), either directly or by the so-called arterial circle of Zinn and Haller (when is present). [36, 37, 38, 39, 40]
the retrolaminar region - is the part of the ONH that lies immediately behind the lamina cribrosa. It is supplied by two vascular systems: the peripheral centripetal and the axial centrifugal systems. The previous represents the main source of stream for this part. It is formed by recurrent pial branches arising from the peripapillary choroid and the circle of Zinn and Haller (when present, or the PCAs instead). In addition, pial branches from the central retinal artery (CRA) also supply this part. The latter is not present in all eyes. When present, it is formed by inconstant branches arising from the intraneural part of the CRA.
From the description of the arterial supply of the ONH given above, it is obvious that the PCAs are the main source of blood supply to the ONH. [36, 37, 38, 39, 40].
\nThe blood flow in the ONH depends upon [36, 37, 38, 39, 40]:
resistance to blood flow - depends upon the condition and caliber of the vessels supplying the ONH, which in turn are influenced by: the efficiency of auto-regulation of the ONH blood flow, the vascular variations in the arteries feeding the ONH circulation, and the rheological properties of the blood.
arterial blood pressure (BP) - both arterial hypertension and hypotension can influence the ONH blood flow in several ways. In an ONH, a fall of blood pressure below a critical level of auto-regulation would decrease its blood flow. Decrease of BP in the ONH may be due to systemic (nocturnal arterial hypotension during sleep, intensive antihypertensive medication, etc.) or local hypotension.
intra-ocular pressure (IOP) - there is an opposite relationship between intra-ocular pressure and perfusion pressure in the ONH.
The blood flow in the ONH is calculated by using the following formula:
\nPerfusion pressure = Mean BP minus intraocular pressure (IOP).
\nMean BP = Diastolic BP + 1/3 (systolic - diastolic BP) [6, 13].
\nAION is the consequence of an acute ischemic disorder (a segmental infarction) of the ONH supplied by the PCAs. Blood supply interruption can occur with or without arterial inflammation. Therefore, AION is of two types: non-arteritic AION (NA-AION) and arteritic AION (A-AION). The prior is far more common than the last, and they are distinct entities etiologically, pathogenically, clinically and from the management point of view. [36, 37, 38, 39, 40].
\nA history of amaurosis fugax before an abrupt, painless, and severe loss of vision of the involved eye, with concomitant diffuse pale optic disc edema is extremely suggestive of A-AION. None of these symptoms are found in NA-AION patients. [36, 37, 38, 39, 40].
\nIn acute stage, blood flow cannot be detected in the PCAs in the clinically affected eye of any of the GCA patients with A-AION. Low end diastolic velocities (EDV) and high resistance index (RI) are identified in all other orbital vessels (including the PCAs in the opposite eye) of all A-AION patients. [9, 10, 11, 12, 13, 14, 41].
\nOver 7 days, Spectral Doppler analysis of the orbital vessels highlights blood flow alterations in all A-AION patients even with a high-dose corticosteroids therapy. Severely reduced blood flow velocities (especially EDV) in the PCAs of the affected eye (both nasal and temporal branches), compared to the unaffected eye, are observed. An increased RI in the PCAs is noted (the RI is higher on the clinically affected eye as compared to the unaffected eye). [9, 10, 11, 12, 13, 14, 41] (Figure 9A,B).
\nCDI of the PCAs in A-AION: (A). Decreased EDV in the nasal PCAs of the clinically affected right eye, and (B) of the clinically unaffected left eye.
Fewer abnormalities are detected in the CRAs: high RI are measured in both sides, with decreased peak systolic velocities (PSV) in the CRA of the clinically affected eye. [9, 10, 11, 12, 13, 14, 41].
\nSimilar abnormalities are noted in the OAs: high RI are measured in both sides. [9, 10, 11, 12, 13, 14, 41].
\nAt 1 month, after treatment with high-dose corticosteroids, CDI examinations of orbital blood vessels reveals that blood flow normalization is slow in all A-AION patients. [9, 10, 11, 12, 13, 14, 41].
\nIn conclusion, the Spectral Doppler Analysis of the orbital vessels in A-AION indicates (after several days of corticosteroid treatment) low blood velocities, especially EDV, and high RI in all orbital vessels, in both orbits. These signs represent characteristic signs of the CDI of the orbital vessels in A-AION. [9, 10, 11, 12, 13, 14, 41].
\nIn contrast, the patients with NA-AION present the following characteristics in acute stage, and at 1 week of evolution:
minor reduction of PSV in PCAs (nasal and temporal) in the affected eye, compared to the unaffected eye.
slight decrease of PSV in CRA of the affected eye, due to papillary edema. [9, 10, 11, 12, 13, 14, 41]:
in OAs, PSV are variable: normal to decreased, according to ipsilateral ICAs status.
Severe ICA stenosis (≥70% of vessel diameter) combined with an insufficient Willis polygon led to diminish PSV in ipsilateral OA. [9, 10, 11, 12, 13, 14, 41].
\nIn 1 month, CDI examinations of orbital blood vessels reveal that blood flow normalization is reached. The exceptions are the cases with severe ipsilateral ICA stenosis/occlusion. [9, 10, 11, 12, 13, 14, 41].
\nIn conclusion, in NA-AION, blood velocities and RI in PCAs are preserved. Similar results were obtained in other studies. [9, 10, 11, 12, 13, 14, 41].
\nFluorescein angiogram and CDI of the orbital vessels data support the histopathological evidence of involvement of the entire trunk of the PCAs in the A-AION (impaired optic disc and choroidal perfusion in the patients with A-AION). On the other hand, in the NA-AION, the impaired flow to the optic nerve head (ONH) is distal to the PCAs themselves, possibly at the level of the para-optic branches (only 1/3 of the flow of the PCAs). [36, 37, 38, 39, 40].
\nThese branches supply the ONH directly (impaired optic disc perfusion, with relatively conservation of the choroidal perfusion). [36, 37, 38, 39, 40].
\nExtremely delayed or absent filling of the choroid has been depicted as a fluorescein angiogram characteristic of arteritic AION and has been suggested as one useful factor by which A-AION can be differentiated from NA-AION. [36, 37, 38, 39, 40].
\nCRAO is the result of an abrupt diminuation of blood flow in CRA, severe enough to cause ischemia of the inner retina. Due to the fact that there are no functional anastomoses between choroidal (PCAs) and retinal circulation (CRA), CRAO determines severe and permanent loss of vision. Therefore, it is very important to identify the cause of CRAO, in order to protect the contralateral eye. Frequently, the site of the blockage is within the optic nerve substance and for this reason, it is generally not visible on the ophthalmoscopy. The majority of CRAO are caused by thrombus formation due to systemic diseases, including GCA. For this reason, all patients with CRAO should undergo a systemic evaluation. [42, 43, 44].
\nThe patients with an unilateral CRAO present at the Spectral Doppler analysis of the retrobulbar vessels the following aspects [9, 15, 16]:
an elevated RI in the CRAs (the RI is higher on the affected side, than it is on the unaffected side); with severe diminished blood flow velocities (especially EDV) in the CRA.
fewer abnormalities are observed in the PCAs, and in the OAs (Figure 10).
CDI of orbital vessels revealed severely diminished EDV and high RI in both CRAs (a, b) despite the fact that the left eye had the normal aspect at ophthalmoscopy. Fewer abnormalities were observed in the PCAs (c, d). [15].
Other imaging techniques, such as high-resolution magnetic resonance imaging (MRI), magnetic resonance-angiography (MR-A), computer tomography angiography (CT-A), positron emission tomography (PET) provide valuable information regarding the structure of large vessels, highlighting with much greater precision the thoracic aorta, compared with US. [45, 46, 47].
\nThere are few studies that compared US with other imaging techniques. Some of them indicated that there is a good correlation between US and PET, even though PET might have a little more sensitivity for vertebral arteries examination. [45, 46] 18F-fluorodeoxyglucose-positron emission tomography/ computed tomography (FDG-PET/CT) has a higher sensitivity for detection of large arteries and aortic involvement - analysis of the arterial wall. [45, 46] The diagnostic power of high-resolution MRI and color-coded duplex US of extra-cranial arteries in detecting GCA are equivalent [47].
\nThe disadvantages of this techniques are: they are more expensive, hardly accessible, some of them are limited by invasiveness, nephrotoxicity (angiography) and exposure to high radiations (CT,PET), this is why they might be unnecessary (excepting those patients with exclusively thoracic aorta involvement) and are not accepted as diagnostic methods in GCA. They should only be used when interventions are required [45, 46, 47].
\nAll these imaging techniques should always be performed by well-trained specialists, using suitable equipment and operational protocols. [45, 46, 47].
\nNevertheless, US is particularly useful in examining the orbital vessels. [9, 10, 11, 12, 13, 14, 15, 16, 28, 31, 32, 41].
\nThe diagnostic work-up of AION benefits from the combined used of fluorescein angiography and noninvasive multimodal imaging, including CDI of the orbital vessels and structural Optical Coherence Tomography (OCT) of the optic nerve head (ONH) and OCT angiography [10, 48]. They provide very detailed information regarding the structural (retinal nerve fiber layer-RNFL-thickness/optic disc edema) and vascular impairments (microvascular defects-vessel tortuosity, and vessel density reduction) of the ONH, respectively [10, 48].
\nUS should be used as a first-line diagnostic investigation for patients presenting with clinical and biological features suggestive for GCA, taking into consideration that it has a high sensitivity to detect vessel wall thickening (dark hallo sign) in the case of large/medium vessels. In a few cases of our studies, the CCAs and the ICAs were also involved.
\nIn consequence, in our department, CCDS has emerged as a safe and reliable alternative to TAB as a point of care diagnostic tool in the management of temporal arteritis.
\nThe eye involvement in GCA is frequent and consists in A-AIONs or CRAO, with abrupt, painless, and severe loss of vision of the involved eye.
\nBecause findings of TAs US do not correlate with eye complications in GCA, CDI of the orbital vessels is of critical importance, in order to quickly differentiate the mechanism of eye involvement (arteritic, versus non-arteritic). This US tehnique may be helpful to detect the blood flow in the orbital vessels, especially in cases of opacity of the medium, or when the clinical appearance of ophthalmologic complications in temporal arteritis is athypical.
\nThe Spectral Doppler Analysis of the orbital vessels in GCA with eye involvement reveals low blood velocities, especially EDV, and high RI in all orbital vessels, in both orbits, for all patients (especially on the affected side).
\nA huge advantage of CDI of orbital vessels is that it provides immediate information that can be used to inform treatment decisions, including a potential reduction in loss of sight and avoidance of unnecessary long-term steroid treatment by early exclusion of mimics.
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