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This chapter considers how moral duties not to harm and those to aid differ, the idea of morally innocent threats, and the role of self-defense in making one safe when not all are safe. These ideas are used to help justify twelve proposals for dealing with future pandemics, including some moral requirements, that aim to be consistent with the views of even those most concerned about personal liberty. The chapter also examines the limits some moral philosophers recommend on interpersonally aggregating losses and benefits and how this affects the morality of hospitals postponing elective medical procedures and the morality of requiring lockdowns. It concludes that imposing relatively small harms on each of many people in order to prevent loss of others’ lives could sometimes be justified to those with libertarian-like views.

Environmental and lifestyle factors play an important role in the natural history of Crohn's disease and ulcerative colitis. A group of international experts from the International Organization for the Study of Inflammatory Bowel Diseases voted on a series of consensus statements to inform the management of inflammatory bowel disease (IBD). The recommendations include avoiding traditional cigarette smoking in patients with Crohn's disease or ulcerative colitis, screening for symptoms of depression, anxiety, and psychosocial stressors at diagnosis and during flares (with referral to mental health professionals when appropriate), and encouraging regular physical activity as tolerated. Patients using dietary approaches for treatment of their IBD should be encouraged to adopt diets that are best supported by evidence and involve monitoring for the objective resolution of inflammation. We recommend formal assessment for obesity and nutritional deficiencies, and patients should be encouraged to maintain a normal body-mass index. A shared decision-making approach to contraception should include the consideration of IBD-related factors, and risk factors for venous thromboembolism. Long-term or frequent use of high-dose non-steroidal anti-inflammatory drugs should be avoided. For primary prevention of disease in the offspring of patients with IBD, we recommend avoiding passive exposure to tobacco, using antibiotics judiciously, and considering breastfeeding when able.

In this paper, I consider the idea of meaning in life as I believe it has arisen in some discussions of ageing and death. I critically examine and compare the views of Atul Gawande and Ezekiel Emanuel, connecting their views to the idea of meaning in life. I further consider the relation of meaning in life to both the dignity of the person and the reasonableness of continuing or not continuing to live. In considering these issues, I evaluate and draw on Bernard Williams’ distinction between categorical and conditional desires, Susan Wolf's work on meaning in life, and Jeremy Waldron's views on dignity in old age.

This chapter further considers issues that result from there being different measures of the stringency of both rights and duties and shows how this bears on the Trolley Problem. The chapter first reviews the relations between making personal sacrifices, fulfilling personal duties, and promoting the greater good and then focuses on whether fulfilling certain duties could require us, contrary to the relations described, to make sacrifices ordinarily considered supererogatory to promote the greater good. Duties to aid are discussed and then compared to the kinds of duties to refrain from harming others with which Judith Thomson and Derek Parfit are concerned. The chapter concludes by considering Parfit’s view that nonconsequentialism can result, incorrectly, in an agent’s deontological permission to do harm varying depending on the permissions other agents have to do harm. He attributes this to nonconsequentialism’s focus on action for a personal rather than a common aim.

SMIFH2 is a small molecule inhibitor of the formin family of cytoskeletal regulators that was originally identified in a screen for suppression of actin polymerization induced by the mouse formin Diaphanous 1 (mDia1). Despite widespread use of this compound, it is unknown whether SMIFH2 inhibits all human formins. Additionally, the nature of protein/inhibitor interactions remains elusive. We assayed SMIFH2 against human formins representing six of the seven mammalian classes and found inhibitory activity against all formins tested. We synthesized a panel of SMIFH2 derivatives and found that, while many alterations disrupt SMIFH2 activity, substitution of an electron-donating methoxy group in place of the bromine along with halogenation of the furan ring increases potency by approximately five-fold. Similar to SMIFH2, the active derivatives are also pan-inhibitors for the formins tested. This result suggests that while potency can be improved, the goal of distinguishing between highly conserved FH2 domains may not be achievable using the SMIFH2 scaffold.

Background The randomised STRIDENT (Stricture Definition and Treatment) trial showed that Crohn’s disease symptomatic strictures are responsive to anti-TNF therapy with most patients clinically improved after 12 months treatment with adalimumab +/- thiopurine. Treat to target intensification resulted in greater stricture morphology improvement. We present here 2 year (from study entry) follow up to assess response durability and risk of surgery. Methods Patients with symptomatic Crohn’s disease strictures and associated inflammation (elevated faecal calprotectin and CRP) were assessed with imaging (intestinal ultrasound and MRI) and ileo-colonoscopy. The Obstructive Symptom Score (OSS) was used for clinical assessment. Patients were randomised 2:1 to high dose adalimumab induction (160mg weekly for 4 weeks) followed by 40mg fortnightly plus thiopurine, with adalimumab dose increase at 4 and/or 8 months if evidence of ongoing inflammation, versus standard dose adalimumab monotherapy. The primary endpoint was improved OSS at 12 months. Patient interview was conducted at 24 months, assessing drug treatment, symptoms, need for endoscopic therapy, hospitalisation and surgery. Results In the initial 12 months study 52 patients were randomised to the intensive and 25 to the standard treatment arm. 64/77 (83%) patients recorded an outcome at 12 months (13/77 (17%) withdrawn: 8 surgery, 5 other) 74/77 (96.1%) patients were followed up at a mean of 25.3 (IQR 24.4-26.3) months. Of these, 59 (79.7%) remained on adalimumab, 10 (13.5%) had switched to another biologic and 5 (6.7%) had ceased biologic therapy. For patients who were on adalimumab at 12 months the risk of surgery by 24 months was 15%. Of patients on adalimumab 40mg fortnightly at 12 months, 12/48 (25%) had been dose escalated by 24 months. Endoscopic balloon dilatation, hospitalisation or surgery was required in 6 (8.1%), 14 (18.9%) and 13 (17.5%) respectively; rates were not different between the standard and intensive treatment groups (P = 0.982). Median time to intestinal resection was 12.2 (IQR 6.9-18.6) months. Clinical responders at 12 months, compared to non-responders, had a reduced likelihood of surgery at 24 months (9% vs 42%, P=0.003). Conclusion Clinical response to adalimumab for structuring Crohn’s disease is durable in a majority of patients, with most patients remaining on adalimumab and avoiding surgery at two years. Rates of surgery were not different between the standard and intensive therapy arms. Clinical response to adalimumab at 12 months is an important predictor of future surgical risk.

SMIFH2 is a small molecule inhibitor of the formin family of cytoskeletal regulators that was originally identified in a screen for suppression of actin polymerization induced by the mouse formin Diaphanous 1 (mDia1). Despite widespread use of this compound, it is unknown whether SMIFH2 inhibits all human formins. Additionally, the nature of protein/inhibitor interactions remains elusive. We assayed SMIFH2 against human formins representing six of the seven mammalian classes and found inhibitory activity against all formins tested. We synthesized a panel of SMIFH2 derivatives and found that, while many alterations disrupt SMIFH2 activity, substitution of an electron-donating methoxy group in place of the bromine along with halogenation of the furan ring increases potency by approximately five-fold. Similar to SMIFH2, the active derivatives are also pan-inhibitors for the formins tested. This result suggests that while potency can be improved, the goal of distinguishing between highly conserved FH2 domains may not be achievable using the SMIFH2 scaffold.

Background Diet is an accepted therapy for Inflammatory Bowel Disease (IBD). Controlled trials have demonstrated that exclusive enteral nutrition (EEN) and the Crohn’s Disease Exclusion Diet (CDED) induce remission in Crohn’s disease. Low sulphur and plant-based diets are being investigated in ulcerative colitis (UC). Reducing ultra-processed, additive-containing food intake is emerging as important, given its role in initiating and perpetuating disease. IBD patients believe in the value of the diet, but there is no evidence for diet tolerability and benefit outside of clinical trials. The DELECTABLE program, a dietitian-led telehealth service, aims to evaluate structured, evidence-based dietary therapy as part of routine clinical care. Here we present satisfaction, compliance and efficacy results. Methods In this open-label, prospective, observational program, Crohn’s disease and pouchitis patients were offered the CDED or a wholefood additive-free diet, UC patients were offered a low-sulphur plant-based diet or wholefood diet, and patients with microscopic colitis were offered the wholefood diet. The primary outcome was diet satisfaction (modified DSAT-28; possible range: 28 to 140). Dietitian-rated compliance, patient-rated compliance, disease activity score (CDAI, partial Mayo score), CRP, and faecal calprotectin were secondary outcomes. Baseline to week 12 differences were assessed using the Mann-Whitney-U-test or Wilcoxon-sign-test for continuous variables and McNemar’s test for categorical variables. Results Of 165 patients referred, 79 enrolled in the program. Fifty-seven (72%) enrolled patients have completed 12 weeks of diet therapy. Across all diet arms combined, diet satisfaction score increased from week 1 (89.3) to week 12 (93.7; P Conclusion Half of the referred patients are interested in pursuing a supervised, long-term diet program. Implementation of well-balanced, effective diet therapies is feasible and well-accepted by patients, with a promising impact on disease activity.

This chapter first considers the idea of an entity’s moral status as what it is permissible or impermissible to do to it and examines how its status so understood relates to whether it is sentient, conscious, capable of agency, a subject, or rational. The chapter then considers ways in which the moral status of embryos that will definitely develop into persons differs from the status of those persons. It considers implications of this for the Non-Identity Problem and the so-called No-Difference View about it.

Background The modified Rutgeerts’ score (mRS) differentiates i2a – lesions confined to the anastomosis – and i2b – neoterminal ileum lesions – categories. Its relevance for therapeutic management of Crohn’s disease (CD) patients after ileocolonic resection is still debated. Our objective was to compare the postoperative recurrence (POR) risk in patients with a mRS i2a or i2b score using an individual patient data meta-analysis. Methods We conducted a systematic literature search of Medline, Embase and abstracts from international conferences (until July 2020) to identify all relevant studies reporting the risk of clinical and/or surgical POR and the i2a/i2b status in the year following ileocolonic resection. Initial datasets were obtained from the corresponding authors. Time from endoscopy to clinical and surgical POR was estimated using Kaplan-Meier method. The association between time to event and mRS was evaluated using a mixed Cox with centre as the random effect. Results From the 17 studies identified, 7 published between 2008 and 2019 (cohort studies, n=4; clinical trials, n=2) corresponding to a total of 400 patients (median (InterQuartileRange) age at surgery 34 (26,47) years; 52% female) were included. In the year following ileocolonic resection, 189 (47%) patients displayed an i2a mRS and 211 (53%) an i2b. In the i2b group, we observed more male patients (56% versus 41%, p=0.01), more patients with previous ileocolonic resection (31% versus 21%, p=0.03) and temporary ileostomy (14% versus 6%, p=0.03) and an immunosuppressant or antiTNF therapy was more frequently initiated after endoscopy (42% versus 26%, p Conclusion In this individual patient data meta-analysis, no difference is observed between i2a and i2b mRS subcategories in terms of clinical, surgical or endoscopic POR. Limits of the mRS may explain this lack of predictive value.

AIM AND OBJECTIVES To explore and understand the current practice, perceptions, and knowledge of general surgery trainees, advanced practice providers, and surgical nurses regarding opioid prescribing and administration. To this end, a novel opioid education and training was introduced to educate these practitioners on safe opioid practices in surgical patients. BACKGROUND National awareness of the opioid epidemic has increased significantly in the last several years. However, there remain a disturbingly high number of opioid prescriptions written in the US indicating a need for improved provider and nurse education. This involves increasing awareness and understanding of national guidelines as well as implementing multi-modal therapy to treat pain. DESIGN Pre-post-intervention quality improvement project. METHODS An opioid education and training involving a morphine equivalent daily dosing calculator in the electronic medical record was provided to 26 surgical trainees, eight advanced practice providers and 97 surgical nurses in November 2019. Perceptions, current practice and knowledge were measured using a pre- and post-intervention survey (SQUIRE checklist). RESULTS The survey results showed a positive clinical change in perception of opioid use in surgical patients following the intervention and a modest decrease in the average morphine equivalent daily dosing at discharge in general and transplant surgery patients. CONCLUSIONS Effective pain management for surgical patients must be individualised. Safe opioid prescribing should involve an interdisciplinary approach with all members of the team undergoing assessment of their opioid knowledge and prescribing habits, easily accessible training tools and opioid calculators in the electronic medical record. RELEVANCE TO CLINICAL PRACTICE Our initiative may provide useful information to settings that replicate use of a morphine equivalent daily dosing calculator in the electronic medical record. Utilisation of safe opioid prescribing tools in the electronic medical record and continuing education for providers and nurses can help ensure the safety of surgical patients.

Background Appendiceal mucinous neoplasms (AMNs) are a rare and complex spectrum of disease involving a mucinous tumor within the appendix, which can range from benign to malignant. If not limited to the appendix, the mucinous tumor can spread diffusely throughout the peritoneum. Objectives Because of the low incidence of AMN, this study describes the diagnosis and treatment process for this disease, which is not well known to most care providers. Methods An extensive analysis of the current literature, including incidence, diagnosis, and surgical treatment, was performed. A review of the pre- and postoperative needs for patients undergoing surgery was also conducted. Findings There is minimal information in the nursing literature about AMN and the complexity of surgical management. Nurses play an important role in caring for these patients and their unique needs both before and after surgery.

This book is a discussion of philosophical, legal, and medical issues related to aging, dying, and death. It considers different views about whether and why death is bad for the person who dies, and whether these views bear on why it would be bad if there were no more persons at all. The book looks at how the general public is being asked to think about end-of-life issues by examining some questionnaires and conversation guides that have been developed. It also considers views about the process of dying and whether it might make sense to not resist death, or even to bring about the end of one’s life, given certain views about meaning in life and what things it is worth living on to get and do. Some hold that it is not only serious illness but ordinary aging that may give rise to some of these questions and the book considers various ways in which aging and the distribution of goods and bads in a life could occur. Physician-assisted suicide would be one way to end one’s life and the book examines arguments about its moral permissibility and whether or not it should be legalized as a matter of public policy. This discussion draws on capital punishment debates concerning state action and also on methods of balancing costs and benefits. The book examines the views of such prominent philosophers, doctors, and legal theorists as Shelly Kagan, Susan Wolf, Atul Gawande, Ezekiel Emanuel, Cass Sunstein, Neil Gorsuch, and others.

Chapter 4 considers proposals for advanced and end-of-life care and for helping the general public make decisions about such care. Possible conflicts are identified between the aim of respecting people’s preferences and meeting objective standards of best practices, satisfying family preferences, and meeting requirements of informed consent. The chapter considers in detail questions suggested for conversations about advanced and end of life care. It locates imprecision, nudging, and framing effects in those questions that may interfere with their correctly eliciting people’s preferences. It also suggests that there may be attempts to promote specific values and goals favored by end-of-life care professionals, such as peacefulness and avoiding invasive treatments. The possible connection between the aim of a good life to the end and the use of assisted suicide is also examined.

This chapter presents five arguments in favor of the moral permissibility of, and even a duty to engage in, physician-assisted suicide both to end suffering and for other reasons in those who are and are not terminally ill. It considers objections to these sorts of arguments presented by David Velleman from a Kantian perspective and by Neil Gorsuch (now associate justice of the U.S. Supreme Court) who argues against intentionally causing death. The chapter considers how to identify intention, the significance of it for moral and legal permissibility, and the role of the Doctrine of Double Effect in arguments about assisted suicide. It also deals with the difference between assisted suicide for the good of some enabling versus causing harm to others.

Chapter 3 discusses Atul Gawande’s views about the choice between trying to live on by way of medical treatment and trying to retain meaning during one’s dying process through hospice care. It first compares medical and philosophical conceptions of death and dying. It then considers how Gawande’s views relate to Bernard Williams’ distinction between categorical and conditional desires and how they compare with views discussed in Chapter 2 about when it can make sense not to resist the end of one’s life. There is discussion of Gawande’s conception of the dying role, fear, the importance of how things end, and meaning in life. Suggestions are offered about possible meaningful use of suffering and death.

Chapter 2 discusses Shelly Kagan’s views about (i) when ending or not ending one’s life does or does not make sense, and (ii) how to reach a decision about this issue. It considers whether his views about the worth of living on are consistent with his views about when it makes no sense to end one’s life. The chapter also examines whether the way in which Kagan adds up the negative and positive aspects of life to decide whether to live on gives sufficient weight to context-dependent values and to the reasonableness of not going through great suffering for the sake of an even greater good to oneself.

Chapter 6 examines Ezekiel Emanuel’s reasons for thinking that after a “complete life” (by around age seventy-five) it can be reasonable (at least for some) to omit easy preventive measures (e.g., flu shots) that would extend life even when such life would not be worse than death. To better understand such a position the chapter makes use of the views of Susan Wolf and Bernard Williams on meaning in life and reasons to go on living, and also considers different ways of judging the worth of activities. It further compares Emanuel’s views with those of Atul Gawande, B. J. Miller, and Douglas MacLean. Finally, it considers whether Emanuel’s arguments succeed and also whether they support the moral permissibility of suicide and assisted suicide.

Chapter 5 distinguishes qualitative aging from becoming older in years by considering the fictional case of Benjamin Button. It then considers the significance and necessity at a given time of death in lives with different aging trajectories. There follows a discussion of better and worse distributions of goods and bads within lives, both on the assumption that we have and do not have control over the total of goods and bads and the length of life. Finally the chapter considers how the difference between conditional and categorical goods may affect appropriateness of tradeoffs between quantity and quality of life.

Chapter 8 considers how one should reason about assisted suicide as a matter of public (and legal) policy in the absence of a constitutional right to it by critically examining anti-legalization views such as those of Ezekiel Emanuel. The chapter considers the role of (i) moral rights and wrongings and how they come about as well as (ii) harms and benefits and how to aggregate them. How arguments for the distinctive role of the state in enabling or interfering with behavior bears on these issues is considered by reviewing some arguments about capital punishment. Finally, in the light of empirical data about effects of legalizing physician-assisted suicide and given what else Emanuel believes, the chapter considers whether he should no longer oppose legalization.

Background High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. Purpose This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. Method An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. Findings A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. Discussion A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

This chapter surveys different accounts of the factors that make death bad and that make one death worse than another both intrapersonally and interpersonally. It focuses on (1) deprivation of future goods of life (Deprivationism); (2) having had fewer rather than more goods at the time of death (Willhavehadism); (3) being all over as a conscious person (Alloverism); and (4) vulnerability to loss and decline to nothingness (Insult). For each account of the badness of death, the chapter considers (a) possible problems with it and how they might be solved; (b) possible good and bad ways to remedy or ameliorate the bad; and (c) the morality of pursuing such remedies or amelioration. It also considers some related issues, including (i) whether to help those who are worst off; (ii) the role of moral rights; (iii) the significance of a human’s developmental stage; (iv) the value of mere conscious personhood; and (v) prenatal nonexistence.

813 Background: Despite published evidence based interventions for malignant bowel obstruction (MBO), implementation of a standard pathway is challenging. We hypothesized that using industrial engineering techniques and a modified dynamic sustainability framework for implementation, we can implement an electronic medical record (EMR) based pathway in the management of MBO. Methods: A workflow in the management of MBO was developed using iterative meetings from 8/2018 to 4/2019 including gateway stakeholders (surgical oncology, gynecological oncology and medical oncology), interventional stakeholders (gastroenterology, interventional radiology) and supportive stakeholders (hospital medicine, palliative care, nutrition, nursing). Industrial engineers were utilized to study human factors, and perform a method study. EMR integration was performed using EPIC systems Agile MD pathway and educational materials were created. Interventions such as early placement of gastrostomy tubes, total parenteral nutrition and medications were protocolized. Results: Since implementation, over 6 months the pathway and order set has been activated 56 times. Orders have been employed 21 times through the AgileMD pathway demonstrating a pathway drift of 62.5%. Educational materials have been accessed routinely during this time. Conclusions: Feasibility of implementing an EMR integrated MBO pathway is demonstrated with early suggestion of pathway drift. Utilizing tools of implementation science are necessary to facilitate widespread adoption of evidence based interventions in the management of patients with MBO.

Based on our long-standing Intensive Training Program for Effective Teaching Assistants in Chemistry, we have developed an Advanced Training Course for Teachers and Researchers in Chemistry at The University of Chicago. The topics in this course are designed to train graduate teaching assistants (GTAs) to become effective teachers and well-rounded PhD candidates. The goals of the course are to build ethics, critical thinking, and a positive self-image as a teacher through the use of a variety of pedagogical tools. Concurrently, the GTAs are transitioned into independent researchers with the skills to prepare written reports and oral presentations. The goals of this course were achieved based on the results of participant feedback. The experience gained and issues identified from the course may be used to guide future training courses.

Monolayers of five-coordinate gallium octaethylporphyrin complexes (Ga(OEP)X; X = Cl, Br, I, O3SCF3, CCPh) on highly oriented pyrolytic graphite were studied at the solid-liquid (1-phenyloctane) interface using scanning tunneling microscopy (STM) to probe the dependence of their properties on the nature of the axial X ligand. Density functional theory calculations of the gas-phase structures of the free molecules reveal that the gallium atom is positioned above the plane of the porphyrin macrocycle, with this pyramidal distortion increasing in magnitude according to X = O3SCF3 (displacement = 0.35 Å)Cl, Br, I (∼0.47 Å)CCPh (0.54 Å). All compounds exhibit pseudohexagonal close-packed structures in which the porphyrin is oriented coplanar with the surface and the axial ligand is oriented perpendicular to it, and with unit-cell parameters that are within experimental error of each other (a, b = 1.34 (3)-1.39 (2) nm, Γ = 66 (2)-68 (1)°). In contrast to these close similarities, the stabilities of the monolayers are sensitive to the nature of the axial ligand: the monolayers of Ga(OEP)(O3SCF3) and Ga(OEP)(CCPh) exhibit damage during the STM experiment upon repeated scanning and upon toggling the sign of the bias potential, but monolayers of Ga(OEP)Cl, Ga(OEP)Br, and Ga(OEP)I do not. A second important ligand-influenced property is that Ga(OEP)I forms bilayer structures, whereas the other Ga(OEP)X compounds form monolayers exclusively under identical conditions. The top layer of the Ga(OEP)I bilayer is oriented with the iodo ligand directed away from the surface, like the bottom layer, but the molecules pack in a square, lower-density geometry. The comparatively large polarizability of the iodo ligand is suggested to be important in stabilizing the bilayer structure.

Eine mogliche Ursache fur Fieber unklarer Genese („fever of unknown origin“, FUO) ist das maligne neuroleptische Syndrom (MNS). Das MNS ist eine potenziell letale Nebenwirkung verschiedener Medikamente, u. a. der Neuroleptika. Die typischen Leitsymptome sind die Entwicklung von schwerem Rigor und Temperaturerhohung in Verbindung mit neuroleptischer Medikation. Im Fallbeispiel wird uber einen Patienten mit einer schizoaffektiven Storung berichtet, bei dem die Diagnose des MNS initial nicht eindeutig war. Letztlich konnten bei Fieber und einer massiv erhohten Kreatinkinase(CK)-Konzentration als Zeichen einer Muskelschadigung die Diagnose gestellt und eine adaquate Therapie mit Dantrolen, Bromocriptin und Amantadin eingeleitet werden.

Ultrafast transient absorption measurements reveal that the rate constant for photoinduced electron transfer (PET) from colloidal CdS quantum dots (QDs) to alkylcarboxylate-functionalized viologens is independent of the number of methylene groups in the alkyl chain (n). The rate constant for PET is (1.2 ± 0.3) × 1010 s–1 for n = 1, 2, and 3, and for n = 0 (methylviologen). The insensitivity of the electron transfer rate constant to the length of the functional groups on the viologen suggests that a “through-space” pathway, where the electron bypasses the alkylcarboxylate and tunnels instead through only the orbitals of the QD and of the bipyridinium core, is the dominant PET pathway.

Anamnese und klinischer Befund: Eine 74jahrige Patientin litt seit 3 Wochen unter wasrigen Diarrhoen und diffusen Bauchschmerzen. Sie war unruhig, hatte subfebrile Temperaturen bis 37,8°C, war tachykard, und der Blutdruck betrug 190/90 mm Hg. Kurz nach Aufnahme entwickelten sich Petechien an den Unterschenkeln und Gelenkbeschwerden. Untersuchungen: Klinisch-chemisch wurde eine manifeste Hyperthyreose gesichert. Die Hautbiopsie ergab eine leukozytoklastische Vaskulitis. Antinukleare Antikorper, Antistreptolysintiter, Rheumafaktor, Kryoglobuline und TSH-Rezeptor-Antikorper waren negativ, Immunglobulin A war erhoht. Therapie und Verlauf: Unter dem Verdacht auf eine medikamentos (Thyreostatika) induzierte Vaskulitis begannen wir eine Therapie mit Methylprednisolon 100 mg/d. Wegen einer grosen Proteinurie (5,6 g/d) erfolgte eine Nierenbiopsie mit dem Ergebnis einer fokalen Glomerulonephritis mit Depots von Immunglobulin A, Fibrin/Fibrinogen und Komplementfaktor 3. Eine aufgrund einer gastrointestinalen Blutung durchgefuhrte Gastroskopie ergab das histologische Bild einer nekrotisierenden Vaskulitis. Somit wurde die Diagnose einer Schonlein-Henoch-Purpura gesichert. Da sich der klinische Zustand rapide verschlechterte, wurde zusatzlich eine Cyclophosphamidtherapie (2 mg/kg) eingeleitet. Am 17. Tag nach der Aufnahme starb die Patientin plotzlich an einer akuten kardialen Dekompensation. Folgerung: Der ungunstige Krankheitsverlauf bei der betagten Patientin zeigt eine bisher nicht beschriebene enge zeitliche und klinische Korrelation einer Schonlein-Henoch-Purpura mit einer Hyperthyreose. History and clinical findings: A 74-year-old woman had for 3 weeks suffered from watery diarrhoea and diffuse abdominal pain. She felt restless, had a subfebrile temperature (37.8°C), tachycardia and a blood pressure of 190/90 mm Hg. Shortly after admission petechiae were found over the lower legs and she complained of joint pains. Investigations: Laboratory tests established hyperthyroidism. Skin biopsy showed leucocytoclastic vasculitis. Tests for antinuclear antibodies, antistreptolysin titre, rheumatoid factors, cryoglobulins and TSH-receptor antibodies were negative, immunoglobulin A (IgA) was raised. Treatment and course: As a drug-induced vasculitis was suspected treatment was started with methylprednisolone, 100 mg daily. Proteinuria (5.6 g daily) indicated renal biopsy, which revealed focal glomerulonephritis with deposits of IgA, fibrin/fibrinogen and complement factor 3. Gastroscopic biopsy, performed after an episode of gastrointestinal bleeding, demonstrated necrotizing vasculitis, confirming the diagnosis of Schonlein-Henoch-purpura (SHP). As the patient's condition rapidly worsened, cyclophosphamide was started additionally (2 mg/kg). She died on the 17th hospital day from acute cardiac failure. Conclusion: The lethal course of the disease in this elderly patient illustrates a previously not reported close temporal and clinical relationship between SHP and hyperthyroidism.

consider several proposals for why ST is wrong, including the possible distinctiveness of terror, the fact that victims are civilians, and the fact that an agent intends the harm and terror. I shall argue that terror is not the most serious wrong of terrorism and that the intention of the agent is not what makes his act wrong. To support the latter claim, I shall consider cases in which acts are either not terrorism or remain permissible even when an agent intends harm and terror. I shall then offer an alternative characterization of the most serious part of the wrong of terrorism. However, I shall also consider some factors that could sometimes make terrorism permissible. Finally, I shall try to draw some implications of my discussion for "real world" policy. Although this last part of the discussion may not add anything in purely philosophical terms, it seems appropriate for a moral philosopher whose work bears on public policy to suggest ways in which public pronouncements and rules could be made more accurate.

This article presents a three-step argument for the moral permissibility of physician-assisted suicide (PAS) and euthanasia (E). After a brief discussion of how death could sometimes be in a persons best interests and a lesser evil than other bad things that might happen to her, author presents the Three-Step Argument. EUTHANASIA involves a death that is intended in order to benefit the person who dies. The two premises death involves a lesser evil and imminence of death has different implications in cases in which the patient is not terminal. Using this premise people could construct an Alternative Three-Step Argument. The second premise is that doctors could permissibly intend greater evils other than death that will occur imminently anyway in order to produce a lesser good. The conclusion is that it is permissible for doctors to intentionally kill a terminally ill patient in order to stop pain, even if death is the greater evil and relief of pain the lesser good.

Neuroleptic malignant syndrome (NMS) is a possible cause of fever of unknown origin (FUO) and is a potentially fatal adverse effect of various drugs, especially of neuroleptics. First generation antipsychotics, such as received by the patient described in this article, are more likely to cause NMS than second generation antipsychotics. The key symptoms are the development of severe muscle rigidity and elevated temperature associated with the use of neuroleptic medication. Malignant catatonia (MC) is an important differential diagnosis of NMS. While neuroleptics can trigger NMS and must be immediately discontinued if NMS occurs, neuroleptic therapy represents the first line treatment for MC. This article describes the case of a patient with schizoaffective disorder where initially the diagnosis of NMS was not clear. Eventually, fever and a markedly elevated serum creatine kinase (CK) led to the correct diagnosis and the appropriate therapy with dantrolene, bromocriptine and amantadine. Furthermore, a thorough review of the currently available literature on NMS is provided.

The natural product L-carnitine is--due to its biotechnological accessibility and specific properties--on the way to becoming an attractive biobased bulk product. L-carnitine is a natural betaine with vitamin properties. Carnitine is an essential part of the fatty acid metabolism of human beings and animals. Carnitine was first isolated in 1905 from meat extract and important recent developments include the biosyntheses of L-carnitine from L-lysine or gamma-butyrobetaine. Our synthesis routes are designed to maintain the primary structure and specific properties of carnitine, such as hydrophilicity and "stiffening" effects for polymeric structures and applications. L-carnitine is converted via lactonization or olefinization into polymerizable basic molecules. The properties and the applications of carnitine polymers are described.