Acute myocardial infarction (AMI) is a common disease in the Western world and has been the topic of much research. Conducting clinical trials with patients in the acute phase of a myocardial infarction, however, poses an ethical challenge. As patients are often under extreme stress and require urgent medical attention, the process of informed consent is severely constrained. Furthermore, the very procedure of informed consent, which is supposed to protect eligible patients, may be a (...) cause of harm in itself due to the delay in the provision of therapy which it causes. This paper describes how physicians have dealt with the informed consent process in various AMI trials and summarizes the results from empirical studies of the consent process of such trials. Finally, the ethical issues and their implications for future trials involving this particular group of patients are discussed. (shrink)

This study aimed to investigate the status and risk factors of post-traumatic stress disorder in patients with acute myocardial infarction after emergency percutaneous coronary intervention in acute and convalescence phases. A longitudinal study design was used. Two questionnaire surveys were conducted in the acute stage of hospitalization, and 3 months after onset in patients. Logistic regression was used to analyze the risk factors for PTSD in AMI patients. The incidence of PTSD was 33.1 and 20.4% (...) in acute and convalescent patients, respectively. The risk factors related to PTSD were door-to-balloon time, left ventricular ejection fraction, smoking, anxiety, and depression. AMI patients after PCI had PTSD in the acute and convalescent stage. The findings indicate that tailored measures should be developed and carried out to prevent PTSD and improve the mental health of patients with AMI after undergoing PCI. (shrink)

Clinical trials for acute conditions such as myocardial infarction and stroke pose challenges related to informed consent due to time limitations, stress, and severe illness. Consent processes shou...

How physicians approach patients and the problems they present is much influenced by the conceptual models around which their knowledge is organized. In this paper the implications of the biopsychosocial model for the study and care of a patient with an acute myocardial infarction are presented and contrasted with approaches used by adherents of the more traditional biomedical model. CiteULike Connotea Del.icio.us What's this?

Definition of the problem: In 1997, Percutaneous Transluminal Coronary Angioplasty (PTCA) was performed in 138.001 cases in Germany. The standard indications, single vessel disease and badly controlled angina, are more and more extended to multivessel disease with and without severe angina, unstable or preinfarction angina, and acute myocardial infarction (AMI) itself. Dilating asymptomatic stenoses of more than 70–80% is a widely used indication, intending prophylaxis of complete occlusion and AMI. Actually there is no generally accepted guideline for (...) the different new indications, conservative versus invasive treatment schedule. It is difficult for the patient to get appropriate information before his decision between mechanical procedures and conservative methods; authentic informed consent actually seems to be in a very bad position. In 1992 the working group called ”Arbeitsgemeinschaft leitender kardiologischer Krankenhausärzte (ALKK)” decided to start a registry of all PTCA procedures, in order to gain knowledge about the present status of PTCA in Germany. Up to March 1999, 198.608 PTCA are logged.Arguments: Each PTCA was included on an intention-to-treat basis. The registry succeeded in a nearly complete recording with 98,6% of all PTCA procedures complete on March 17th, 1999. 93,5% of stenosed and 72,2% of the total occluded vessels were successfully dilated. In 4.729 cases (2,63%) the PTCA caused severe complications. The overall in-hospital mortality was only 0,5%, if the procedures done for AMI were excluded (including AMI it was 1,1%). The calculation of complications should be an essential part of the patients informed consent.Conclusion: Complete recording of all PTCA procedures is feasible even on a nationwide basis. Some results of the registry, as the indication control and the complication rate may help to realize a better doctor-patient-conversation on risks and benefits of either concept. The trend of many CHD patients is ”modern”: It should be done what can be done (mechanically), with results at once. Although said somehow paternalistic, this point of view cannot be tolerated: Proper informed consent today includes the realistic alternative of modern medicaments, especially those with an aggressive cholesterol lowering potency. (shrink)

Increasingly, clinical research is evaluated on the quality of its statistical analysis. Traditionally, statistical analyses in clinical research have been carried out from a ‘frequentist’ perspective. The presence of an alternative paradigm – the Bayesian paradigm – has been relatively unknown in clinical research until recently. There is currently a growing interest in the use of Bayesian statistics in health care research. This is due both to a growing realization of the limitations of frequentist methods and to the ability of (...) Bayesian methods explicitly to incorporate prior expert knowledge and belief into the analyses. This is in contrast to frequentist methods, where prior experience and beliefs tend to be incorporated into the analyses in an ad hoc fashion. This paper outlines the frequentist and Bayesian paradigms. Acute myocardial infarction mortality data are then analysed from both a Bayesian and a frequentist perspective. In some analyses, the two methods are seen to produce comparable results; in others, they produce different results. It is noted that in this example, there are clinically relevant questions that are more easily addressed from a Bayesian perspective. Finally, areas in clinical research where Bayesian ideas are increasingly common are highlighted. (shrink)

Clinical trials give rise to ethical dilemmas, especially in the acutely ill, but we take issue with two points raised in a recent comment on a specific acute myocardial infarction (AMI) trial. The commentators judged that the trial most likely could, and therefore should, have been terminated much earlier. By analysing the problem statistically we arrive at results that go against their intuitive judgment—they also see it as mandatory to update the patient Information sheet as trial results (...) accrue and trends begin to emerge. In our view, interpreting subtle trends and borderline p-values must rest with data monitoring boards, not patients. Moreover, patients with AMI or in other medical emergencies need very simple instructions. Empirical studies of the consent process confirm that the idea of a genuinely informed consent is problematic in such cases. (shrink)

Using dimensional analysis, we demonstrate that it is possible to quantify changes in the topological structure of cardiac dynamics over long periods of time. A method was developed to calculate a dimension-like measure (referred to here as apparent dimension) from a correlation algorithm within a data window of 500 heart beats which is moved in equidistant steps over the time series of the RR intervals over 24 hours. The correspondence between the apparent dimension and the correlation dimension was tested using (...) artificial data sequences. Furthermore 24 hour electrocardiographic recordings of two healthy subjects and of a patient with acute myocardial infarction were examined. The reliability of the analysis could be demonstrated and changes in dimension reflecting physiological as well as pathophysiological changes were observed. (shrink)

BackgroundAcute myocardial infarction (AMI) research is challenging as it requires enrollment of acutely ill patients. Patients are generally in a suboptimal state for providing informed consent. Patients’ understanding to verbal assents have not been previously examined in AMI research. Patients Acceptance and Comprehension to Written and Verbal Consent (PAC–VC) compared patients’ understanding and attitudes to verbal and written consents in AMI RCTs.MethodsPAC–VC recruited patients from 3 AMI trials using both verbal N = 12 and written N = 6 (...) consents. We compared patients’ understanding using two survey questionnaires. The first questionnaire used open-ended questions with multiple choice answers. The second questionnaire used a 5-point Likert scale to measure patients understanding and attitudes to the consent process. Overall answers average scores were categorized into three groups: Adequate understanding (71–100) %, Partial understanding (41–70)% and Inadequate understanding (0–40)%.ResultsResponses showed patients with verbal assent had adequate understanding to most components of informed consent, close to those of written consent. Most patients did not read written information entirely and believed that it is not important to make a final decision. Patients favoured to have written information be part of the consent but not necessarily presented during the initial consent process. Patients felt less pressured in the verbal assent arm than those of written consent.ConclusionPatients had adequate understanding to most components of verbal assent and comparable to those of written consent. Utilizing verbal assents in the acute care setting should be further assessed in larger trials. (shrink)

Advances in medicine are closely linked to clinical research, but certain study procedures may be in conflict with the fundamental principles of ethics and codes of conduct in medicine. Following an analysis of two studies involving treatments for acute myocardial infarction (AMI), the admissibility of continuing a study was questioned after the initial results for two types of treatment showed that one was significantly better than the other. Also considered doubtful was the information provided to patients with (...) the object of obtaining their informed consent. (shrink)

Definition of the problemA myocardial infarction is often a vitally and emotionally threatening situation for the affected. Unconscious coping mechanisms in dealing with the heart disease may result in, for example, complete denial or emotional decompensation.ArgumentAn understanding of myocardial infarction as a borderline situation may provide theoretical enrichment for clinicians and point to a third coping avenue, described as “posttraumatic growth”. Affected individuals often refer to the event as a “wake-up call”. Clinical knowledge of these different (...) coping mechanisms may in turn lead to a relativization of primarily subjectivist positions and substantively hedonistic or preferentialist notions of good life or “quality of life”. Such a position would in turn be compatible with the deliberative model of physician–patient communication.ConsequencesIn the light of such a broader understanding of disease coping, the task of (psychosomatic) physicians would thus to accompany persons with heart disease, to be aware of the teachable moment and to enable a process of development for the patients. (shrink)

The Supreme Court has ruled in the case of Y that there is no requirement to seek the approval of the Court of Protection in decisions to withdraw clinically assisted nutrition and hydration from patients in a prolonged disorder of consciousness.1 Mr Y was 52-year-old man who suffered a cardiac arrest after a myocardial infarction as a result of coronary artery disease. It was not possible to resuscitate him for well over 10 min, resulting in severe cerebral hypoxia (...) which caused extensive brain damage. Mr Y’s family and the NHS Trust treating him agreed that Mr Y would not want to be kept alive through the provision of CANH given his poor prognosis. They sought a declaration that it was not mandatory for applications of withdrawal of CANH to come before the court, which was granted by Mrs Justice O’Farrell in the first instance.2 Permission was granted for the appeal to ‘leapfrog’ the Court of Appeal and to proceed to the Supreme Court for consideration. In the interim, Mr Y died after contracting acute respiratory sepsis, but the Supreme Court determined that the appeal should go ahead in light of the general importance of the issues raised. In delivering the opinion of the Supreme Court on 30 July 2018, Lady Justice Black rejected the historical distinction that had been drawn between patients in PDOC and non-PDOC patients, in a way that had justified judicial involvement for patients in PDOC but not for others.3 She was clear that the correct approach to all cases involving CANH was to make a decision based on what was in the best interests of the patient. She further outlined that: > The documentation supplied to us shows that the difficulty that there is in assessing the patient and in …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Limits of Our ObligationsRyan C. MavesDisclaimers. No funding was utilized for this manuscript. Dr. Maves is a retired U.S. Navy officer, and the opinions contained herein are his own. The opinions in this manuscript do not reflect the official opinion of the Department of the Navy, Department of Defense, nor of the U.S. Government.In 2012, I was a commander in the United States Navy, deployed to the NATO (...) Role 3 Multinational Medical Unit in Kandahar Airfield (KAF), Afghanistan. The KAF Role 3 began as a tent hospital under Canadian command, built along the flight line at Ahmad Shah Baba International Airport as [End Page 176] part of an expanding NATO base. By the time of my arrival, it was a small but capable brick-and-mortar building under U.S. Navy command, with four operating rooms, two CT scanners, and a busy intensive care unit (ICU).Not long before my deployment, the KAF Role 3 was described as one of the busiest trauma hospitals in the world. Casualties arrived every day, usually by helicopter. Blast injuries from improvised explosive devices (IEDs) were common, ranging in severity from concussions in passengers in armored vehicles, to multiple amputations from blast injuries with concomitant thoracic, abdominal, and pelvic trauma. KAF had a daytime population of over 30,000 in 2012, and our hospital was effectively the referral center for the region, so patients with non-surgical diagnoses were similarly common: myocardial infarctions, seizures, pulmonary emboli, and endemic infections, to name a few.As an infectious disease (I.D.) specialist, I functioned mainly as a hospitalist, managing patients postoperatively, but I also provided any consultative support when needed. During mass casualty events, the intensivists and I would act as backups in the trauma bay, freeing up the surgeons for the most acutely injured patients. It turned out that an I.D. doctor’s skillset lent itself well to acute trauma evaluations; we are well known for having an eye for fine details, combined with low-grade paranoia. These traits served me well during what I came to describe as “my involuntary trauma fellowship.”Our patients could be divided into five key groups: Afghan National Security Forces (ANSF, including the army and national police), non-Afghan coalition military (mostly U.S. and other NATO members), Afghan civilians, NATO civilian contract staff, and the Taliban. Our approach to each of these groups was different. For all patient groups, we would provide the same emergency care, including acute resuscitation and immediate life-saving surgery. It was after this emergency care period that our management plans diverged.For coalition forces, our next priority after acute resuscitation and stabilization was to assess whether a patient could remain in theater. Stable patients with relatively minor injuries could often undergo rehabilitation at KAF; many personnel could subsequently return to combat duty with their units. More seriously-injured patients would be transported out of Afghanistan within 24-48 hours (if not faster). Usually, this would involve stops at Bagram Airfield near Kabul and then Landstuhl Regional Medical Center in Germany before reaching a military hospital in their home countries. There were few limits on whom could be transported. Dedicated critical care air transport teams (CCATT) included intensivists, respiratory therapists, and critical care nurses, who could manage the most unstable patients on board what was effectively a flying ICU. The “lung team” in Landstuhl could fly to KAF to start patients with severe respiratory failure on extracorporeal membrane oxygenation (ECMO) and then fly them out on maximal support.NATO civilian contractors would receive comparable care, although the exact details of how they would be transported out of theater would depend on their home countries and the nature of their contract. We cared for one civilian contractor with newly-diagnosed HIV infection whom we were able to stabilize on the ventilator, get him extubated, start on initial antiretroviral therapy, and transport him home with a referral to his local HIV care program.Afghan soldiers were part of the coalition, but there was no distant home country where we could transport them. They were home. After their resuscitations and surgeries, we would arrange transfer to the Kandahar Regional... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:To Be or Not to Be:Waiving Informed Consent in Emergency ResearchCharles R. McCarthy (bio)The requirements for prior, legally authorized informed consent constitute a necessary condition for recruiting subjects into biomedical or behavioral research. However, informed consent requirements pose a serious problem for most research conducted in emergency care settings. For this reason, the Food and Drug Administration's (FDA) regulations governing investigational devices and the Department of Health and Human (...) Services' (HHS) regulations for the protection of human subjects allow narrow exceptions to the general requirements of informed consent. In a joint effort to clarify the applicability of the current FDA regulations and to better understand the intent of the HHS regulations as they apply to emergency research, the FDA and the National Institutes of Health (NIH) cosponsored a public forum on the ethical conduct of emergency research in January 1995.Although the forum was not designed as a consensus conference and participants vigorously disagreed on some of the details, a broad consensus emerged on several major points: (1) both HHS and FDA regulations should, in the immediate future, be interpreted to allow for randomized clinical trials in emergency situations so long as the subjects are carefully protected; and (2) consideration should be given to producing new, closely harmonized regulations from both agencies that will provide greater clarity concerning what kinds of emergency research may be allowed without obtaining prior informed consent.The FDA-NIH forum in January was occasioned primarily by controversy about the hypothermia research protocol described below, but it is obvious that many other kinds of emergency research also await the outcome of deliberations concerning waiver of informed consent in emergency situations. These include research into the care and treatment of: occlusive stroke; subarachnoid hemorrhage due to intracranial aneurysm; metabolic coma; status epilepticus; cardiac arrest; myocardial infarction; cardiac arrhythmia; hemorrhagic shock; pulmonary embolism; acute asthmatic attack; and poisoning. All of these conditions [End Page 155] are encountered in emergency settings where obtaining informed consent from the patient-subjects to participate in research is seldom possible, and obtaining consent from legally authorized representatives of the subjects is either not feasible, or, if obtained, is of doubtful validity.The Hypothermia Research Case and HHS RegulationsA $7.2 million grant for research on the use of hypothermia in the treatment of severe head trauma, the largest award ever made to the University of Texas Health Sciences Center at Houston, is in danger of expiring before the study is completed. The protocol, which involves the use of cooling blankets to induce hypothermia in patients suffering from severe head injuries, is designed to test the hypothesis that: "Early lowering of the body temperature of patients suffering from severe head trauma to approximately 91 degrees Fahrenheit will slow patients' metabolism and will/will not, as a consequence, reduce the rates of both morbidity and mortality in these patients." The protocol was approved by seven Institutional Review Boards (IRBs), each of which waived the requirement to obtain informed consent from research subjects in accordance with Sec. 46. 116(d) of the HHS Regulations for the Protection of Human Subjects.1However, NIH's Office for Protection from Research Risks (OPRR), which is responsible for assuring compliance with the HHS regulations, has taken a controversial regulatory position by requiring informed consent from a legally authorized representative of each subject to be entered in the hypothermia trial. Because the obtaining of surrogate consent has proved to be very difficult, OPRR's position has slowed the research to a point where it may have to be terminated.At issue in the controversy is a fundamental question of ethics and public policy. Is it ever permissible to involve incompetent subjects in research without either their consent, or the consent of their legally authorized representatives? Pertinent HHS regulations for the protection of human subjects seem to answer the question affirmatively by allowing local IRBs to waive some or all of the elements of informed consent under carefully limited circumstances (45 CFR 46 116(d)). Nevertheless, OPRR has signalled the research community that use of the informed consent waiver provision for the Houston hypothermia study is not permitted under the regulations. OPRR judged that the risks... (shrink)

The present work is aimed at investigating the effects of myocardial infarction and ischemia on induction of ventricular fibrillation. Electrophysiologic effects of global and local ischemia (variation of the dispersion of refractory periods as well as conduction velocity) on initiation of reentry mechanisms was studied by means of computer simulations based on a cellular automata model of propagation of activation wave through a ventricular surface element. A local area of ischemia where effects of the dispersion of refractory periods (...) are investigated is then simulated. This is made using a Gaussian distribution characterized by its mean and standard deviation. These simulations show that ischemia is capable of initiating reentry phenomena which propagate through the whole ventricle; they are responsible for ventricular fibrillation which causes sudden cardiac death, even when ischemia only involves limited parts of the myocardium. Statistical study of the probability of reentries as a function of both of the size of ischemic zones and the rate of dispersion of refractory periods shows that the latter parameter is of primary importance in triggering cardiac reentries. (shrink)

Coping after myocardial infarction. The mediational effects of positive and negative emotions The aim of the study was to examine mediational effects of positive and negative emotions on the relationship between cognitive appraisal and coping after myocardial infarction. Subjects were 163 patients assessed a few days after their first MI episode for cognitive appraisal using the Situation Appraisal Questionnaire developed by Wrześniewski and based on the Lazarus theory. The participants' current emotional state and coping strategies were (...) evaluated with Polish versions of the PANAS and CISS-S, respectively. The data were analyzed using the boostrapping procedure. Resultant models turned out to be similar for threat and loss appraisal, where PEs mediated task-oriented coping, while NEs were found to mediate emotion-oriented coping. A different relationship was found for challenge. Due to a significant intercorrelation among appraisals, mediational models for threat and loss were re-analyzed when controlling for challenge. Nevertheless, even if a situation is perceived as highly stressful, both positive and negative emotions can emerge, resulting in strategies that serve different functions to meet external and internal demands. (shrink)

The article presents the results of research on the relationship between social support and self-care of people with myocardial infarction. 127 patients treated in a rehabilitation centre participated in the study. The Inventory of Socially Supportive Behaviours and the Self-care Questionnaire developed by the author, were used. The findings suggest that persons receiving little support are characterised by lower level of self-care than people with medium and high level of support. No such difference was noted between people with (...) medium and high support level. This suggests that social support is of considerable importance for the changes in the level of self-care only in the case of people previously receiving little support. The research also indicates that informational support is related to higher level of self-care whereas instrumental support is related to lower level of self-care. Emotional support was significant only for the care for social functioning. (shrink)

First, we define the concepts of well-being and happiness at school. Then, we explore well-being at school from the perspective of the teacher-student relationship, both from the point of view of the students and of the teachers. To do this, the main results of two studies carried out in 2019 and 2020, mainly in Quebec, are presented. Finally, the two perspectives, that of the pupils and that of the teachers, are confronted. The results of our analysis highlight the importance of (...) the teacher-student relationship both in the student's school experience and in the teacher's professional practice. The affective nature of the relationship seems to occupy a major place. Suggestions and recommendations for optimizing the quality of the teacher-student relationship, for the happiness of learning or teaching, are proposed. (shrink)

This study is a continuation of the work of Professor Kazimierz Wrześniewski. It concerns the role of curiositytrait in the dynamics of changes in coping and quality of life after a heart attack. The study was attended by 222 people after a heart attack, of whom 140 participated in the three stages of the study: at the beginning and at the end of cardiac rehabilitation and a year after leaving the resort. The participants aged 24-64 years. Curiosity-trait was measured by (...) Spielberger and Wrześniewski’s STPI questionnaire. To assess coping strategies a modified version of the COPE by Carver et al., was used. The specific and general quality of life were measured by the Polish adaptations of MacNew and NHP questionnaires. The level of curiosity-trait significantly differentiated changes in the dynamics of positive reinterpretation, problem solving and resignation, but did not affect the change in quality of life within the year after a heart attack. (shrink)

There is a need to understand more of the risk factors involved in the process from suicide ideation to suicide attempt. Cognitive control processes may be important factors in assessing vulnerability to suicide. A version of the Stroop procedure, Delis–Kaplan Executive Function System Color–Word Interference Test and Behavior Rating Inventory of Executive Function were used in this study to test attention control and cognitive shift, as well as to assess everyday executive function of 98 acute suicidal psychiatric patients. The (...) Columbia Suicide History Form was used to identify a group of suicide ideators and suicide attempters. Results showed that suicide attempters scored lower on attention control than suicide ideators who had no history of attempted suicide. The self-report in the BRIEF-A inventory did not reflect any cognitive differences between suicide ideators and suicide attempters. A logistic regression analysis showed that a poorer attention control score was associated with the suicide attempt group, whereas a poorer cognitive shift score was associated with the suicide ideation group. The results found in this study suggest that suicide attempters may struggle with control of attention or inhibiting competing responses but not with cognitive flexibility. (shrink)

Prologue 1. To begin with, the first principle from Whom all illumination descends as from the Father of Light, by Whom are given all the best and perfect gifts, the eternal Father do I call upon through His Son, our Lord Jesus Christ, that by the intercession of the most holy Virgin Mary, mother of God Himself and of our Lord, Jesus Christ, and of the blessed Francis, our father and leader, He may enlighten the eyes of our mind to (...) guide our feet into the way of that peace "which surpasses all understanding", which peace our Lord Jesus Christ has announced and given to us; which lesson our father Francis always taught, in all of whose preaching was the annunciation of peace both in the beginning and in the end, wishing for peace in every greeting, yearning for ecstatic peace in every moment of contemplation, as a citizen of that Jerusalem of which that man of peace said, with those that hated peace he was peaceable, "Pray ye for the things that are for the peace of Jerusalem". For he knew that the throne of Solomon was nowise save in peace, since it is written, "His place is in peace and His abode in Sion". 2. Since, then, following the example of the most blessed father Francis, I breathlessly sought this peace, I, a sinner, who have succeeded to the place of that most blessed father after his death, the seventh Minister General of the brothers, though in all ways unworthy--it happened that by the divine will in the thirty-third year after the death of that blessed man I ascended to Mount Alverna as to a quiet place, with the desire of seeking spiritual peace; and staying there, while I meditated on the ascent of the mind to God, amongst other things there occurred that miracle which happened in the same place to the blessed Francis himself, the vision namely of the winged Seraph in the likeness of the Crucified. While looking upon this vision, I immediately saw that it signified the suspension of our father himself in contemplation and the way by which he came to it. 3. For by those six wings are rightly to be understood the six stages of illumination by which the soul, as if by steps or progressive movements, was disposed to pass into peace by ecstatic elevations of Christian wisdom. The way, however, is only through the most burning love of the Crucified, Who so transformed Paul, "caught up into the third heaven", into Christ, that he said, "With Christ I am nailed to the cross, yet I live, now not I, but Christ liveth in me" ; who therefore so absorbed the mind of Francis that his soul was manifest in his flesh and he bore the most holy stigmata of the Passion in his body for two years before his death. Therefore the symbol of the six-winged Seraph signifies the six stages of illumination, which begin with God's creatures and lead up to God, to Whom no one can enter properly save through the Crucified. For he who does not enter by the door but otherwise, he is a thief and a robber. But if anyone does enter by this door, he shall go in and go out and shall find pastures. Because of this John says in his Apocalypse, "Blessed are they that wash their robes in the blood of the Lamb, that they may have a right to the Tree of Life and may enter in by the gates into the City"; as if he were to say that one cannot enter into the heavenly Jerusalem through contemplation unless one enter through the blood of the Lamb as through a gate. (shrink)

Don't tell terrible stories—everyone here has enough of their own. Everyone here has a whole bloody sack of terrible stories, and at the bottom of the sack is a hammer the narrator uses to pound you on the skull the instant you dare not believe your ears. Or to pound you when you do believe. Not long ago I saw a tomboyish girl on Khreshchatyk Street demand money of an elderly woman, threatening to bite her and infect her with syphilis. (...) Don't stroll through Volodymyr Hill Park, don't stroll around the botanical garden, and especially don't stroll on Kontraktova Square. Don't stroll anywhere. Don't go to the pavilion with the Golgotha panorama near St. Alexander's Church. Not even the twelve-meter-tall crucified Christ will save you. Don't go outside when it's dark and people turn into shadows a shade darker than dark. Also don't go where you can be seen from far away. Not to imply that people used to be like a bunch of lilies, but now they stink like a cellar of cabbage.The city, which earlier might have had some fun, is now going crazy. It's like a fish in warm water: it doesn't react to anything, swims slowly like it doesn't care if it swallows a hook or not. The excitement and exaltation pass into oppression, just as our necks have sunk into our shoulders, our shoulders into our lumbars, our lumbars into our nether regions. The holiday turns into a funeral, the parades into explosions, depression into mania. Winter passes into summer, people turn into beasts, the hours into ages, and the ages into hours. It's worth simply walking around the city to see a soldier from an unknown army taking a piss near the opera. Farther on is a row of identical old widows selling ball gowns and candelabra. Then there are the aristocrats and manufacturers who throw so much at the prostitutes that they'll soon be richer than their wives.I returned late through the Kyryliv Wood, not heeding all the warnings that I myself have given here. It really is dangerous—the place is famous for it. There's a madhouse nearby, caves where criminals and the sick can hide out. Also, once upon a time, as they say in fairy tales, the great dragon Zmei Gorynich lived here beside the Puchai River. The stench in these places drives away the most committed misanthropes and even one type of philanthrope—that is, perverts. It sounds dumb, but the stench is cleansing. I don't know where it comes from. After the operating theaters and the rooms with amputees, the stench no longer repelled or attracted me; it just was. And this was a great place to think. As I walked, I considered an incident with our patient.The patient, a respectable individual whose name carries too much weight for me to state it directly, one day began to assault people. He nearly strangled a merchant who he believed asked too much for a beaver coat. He likewise wanted to kill his business partner when he didn't say hello loudly enough. But the worst was, he lost all shame of his own nakedness. At first it was the police who took care of it. When our future patient slipped off his pants and undergarments, he was taken to Kyrylivska, which has had means for dealing with such cases dating back to the day when unhinged Cossacks and composers from Kyiv Mohyla Academy were taken there.During the examination we determined that the patient was experiencing a severe breakdown. His wife added that lately, more than once, he had allowed himself strong words in front of the children and often suffered from ennui. Furthermore, she said, the patient had been undergoing treatment for “the French disease” for some years—which was, obviously, where we needed to start.“Syphilis!” Skorsky spat out the matchstick he was chewing on. He was a specialist on the psychological aspects of diseases related to the venereal. “Tertiary syphilis! When poorly treated, over time ‘the French disease’ can destroy the central nervous system. Hence the patient's chicanery. Such theater!”Skorsky and I had not spoken since the incident at Bilinsky's. Meanwhile, something significant had happened to him. The most boring person on earth, Skorsky had simply caught fire. He said hello and kibitzed. I even heard the doctor got drunk alone in his office, then wandered through the forest. Could he be using narcotic substances?“Cocaine!” was the doctor's second proclamation. It was his favorite treatment for the psychological complications of syphilis. Skorsky himself never took what he called “the universal drug”—good for alcoholism and toothaches, neuroses and morphine dependency—though he had read in an article by a respectable Viennese physician, who used cocaine as a panacea, that it was not addictive. That doctor subsequently recanted, but Skorsky paid no attention. He believed the retraction was made under pressure from pharmacologists who had no incentive to cease production of the medications that cocaine might supplant. Their representatives either paid or threatened the Viennese to repent.As the patient was escorted to his room, he assaulted the orderly, Alevtyna. They tried pulling him off her, but, though he released his fingers from her neck, he buried his teeth in her leg. The poor orderly, who had not until then been attacked by a psychotic, nearly died of fear. Later, panic set in over Skorsky's diagnosis. He told her about the consequences of syphilis: grotesque patterns on one's face due to infection of the skin, mucous membranes, cartilage, and bones. He went on about the devastation to the central nervous system, which they had just observed in real life: “The face starts to look like lace some mangy dogs fought over before rolling in the mud.”Alevtyna, who had not yet regained her faculty of speech, straightened up. Ignoring the slavering male orderlies, she bared her leg to get a better look at the wound. She then ran down the hall and out into the garden, where she fell on the ground to rip up grass and small bunches of daisies. Alevtyna ate them along with the soil in their roots.“Minor hysteria. She needs fifteen milligrams of cocaine.”Skorsky took a snuff box out of his pocket and scooped up some white powder with a toothpick made from a goose feather. He gave the order to close Alevtyna's mouth and one of her nostrils, forcing her to snort the medication.We fretted over her so long that evening fell. I decided to walk down, along the ravine, behind the church.It was unlikely there were any large beasts there, but something was rustling. The pits and mounds, ravines, paths, graves of witches whose living sisters flew in the treetops from time to time, the whispers of the forest spirits, the spirits of the nutcases who died in the hospital, the spirits of the monks from the St. Cyril Monastery, Zmei Gorynich and the bogatyrs who wanted to defeat him. The city would be calmer without this forest. I saw the gaps between the trees and went off in the direction of the tram tracks.As I was coming out of the forest, there was a patch of Amanita muscaria that had been trampled into porridge. A bit farther on, the body of Professor Bilinsky lay killed in the blackberry bushes. The way he was lying it looked as though he had not struggled before death. I quickly examined his body but saw nothing out of the ordinary. There were no wounds, no dirt under the fingernails. Animals had not yet smelled the carrion, but swarms of various insects covered him. Oh, why did I have to find the putrid body?The best thing would be to take the tram to his house to inform his relatives. The doors closed, and I noticed my own calm. This death had not evoked any emotions in me other than a feeling of responsibility, the need to tell the family. But also—some alarm at the thought of who the murderer could be. I knew that it was murder.“Your nose is bleeding.” A woman as round as an onion, carrying two baskets full of strawberries, offered me an ironed and starched handkerchief.“Have I dirtied my shirt?”“No, it's as neat as a pin. It's just your nose that's dirty. Wipe it now before you spray blood on my strawberries.”“No one will see the red on red.”“Ah, but it's salty!”“You know why it's not sweet? We'd drink it like syrup.”“Those with Christ in their heart do not talk that way.”“Are your strawberries expensive?”“Why? What?”“I'm checking to see if you have God in your heart.”“Child, if you knew how I have to work for this berry! I have to weed it a hundred times. In a week, the quitch grass grows as high as a horse. And I water it with water I carry from the stream, it kills my arms... ”“How much are the berries?”“They're not for sale. Anyway, soon money won't mean a thing. Soon all money, all these papers made from the skins of sinners on their satanic presses will be annulled. What matters is how we treat each other.”“So if I try your strawberries for free, my ‘thank you’ will be enough?”“Hands off!” she said and thwacked my fingers.I heard loud laughter behind me—same laughter as from the café near the Continental. There was no one sitting near Alina. (This is what fate looks like, remember.) Without asking, I sat next to her, away from the old lady.“Excuse me, but the night before last didn't you, yes, didn't you intrude on my privacy?” She started right away.“I saw it a little differently. Who was that young man with the mustache who paid me for you?”“Are you checking to see if you can flirt?”The tram stopped. People got on and off.“Are you coming back from the hospital?” she asked. “Don't be shocked. My uncle works there. He's told me all about you.”“An uncle by the name of Skorsky?”(Remember: this is what fate looks like.)“Yes. Skorsky's been strange recently—says things that make me wonder if he hasn't lost his mind. Have you noticed anything?”“I don't know.”“You know perfectly well.”“Where are you going?” I tried to change the subject.“I have to send something to my theater friends in Odesa. By the way, they'll be putting on Oedipus Rex soon in Kyiv—in Ukrainian.”“Greek tragedy in Ukrainian! That's a first.”“Exactly. The troupe is rehearsing now in Odesa. The theater where they will perform this fall is being remodeled.”“Wait. Now I remember where I've seen you before—it was at a performance! Vynnychenko's Black Panther and White Bear, at the Bergonier on Fundukleivska.“The same director is doing the Oedipus. He's my friend.”“He's your friend in what sense?”“Again with that tired subject. By the way, I've been thinking about you.”“And I about you.”“That's good. I was thinking not about you, to be precise, but about that elevator you invited me on.”“Who was that man with you?”“Like a broken record! Even if he had been my fiancé, I'm not bought or inherited. I'm not a brooch or a hundred acres of land, and I'm not a house in Kaniv!... Who was with you when you saw Black Panther?“Ah, so.”“Answer!”“That was my mother. She looks very young. She is coming to Kyiv the day after tomorrow. I can introduce you.”“Oh, this is my stop.”I looked out the window and realized that I had long since passed the stop for Bilinsky's.“Can we see each other again?”“We can. But you have only one chance.”Alina the anarchist wrote something on a scrap of paper and handed it to me.Morning, not morning but a thick porridge (I hate porridge). Dew, thick spit, crushed fruits, urine, all on the sparkling cobblestones. The sun, just barely having made its appearance, is already scorching. The human masses scurry and grumble like poorly digested food inside a stomach.I walked diagonally across St. Sofia's Square, then along the perimeter, then one edge, then again diagonally across. I went underground. The basement café of the Continental Hotel was practically empty. I again asked the server to bring the cloth with the embroidered portrait, but I couldn't remember the musician's last name, only that it ended with -sky. The server said that -sky was currently in the southern cities of Yalta and Odesa. I added that Kurbas, the director, Alina's friend, was also in Odesa, rehearsing Oedipus Rex, and that he'd previously put on Black Panther.I was bored, so I walked along Khreshchatyk and then headed down, calling to mind all the Kyiv churches of Podil: there's Birth of Christ, St. Nicholas on the Shore, Intercession, Pyrohoshcha, Holy Presentation, St. Dymytrii Rostovsky, St. Illia's. And also the Epiphany Brotherhood Monastery, Ascension Convent, and St. Katherine's, all these whipped-cream churches on the waffles of our streets. A few of them reminded me of themselves by appearing suddenly out of nowhere.The smells on Kontraktova Plaza where commerce buzzed were like multicolored light bulbs turning on one after another. Here you could catch the aroma of Balabukha jam, which blended with the next smell, English shoe polish at the Raiskys’ shop. Then the crunchy-smelling cabbage from old women standing in a row like herons and spitting out the shells of sunflower seeds. Farther on, the stench of a good-sized rat that crawled under Mrs. Shevchuk's shop where she sells broadcloth. Oh, she can't scream: no, she'll quietly dig that rat out herself so as to not scare off her clients.I bought a paper and two pairs of underwear. I asked two laughing young chambermaids who were secretly puffing in a grape-filled yard for a smoke. I wandered around Podil until evening when I came across a sawmill near the Dnipro that surprisingly smelled pleasantly of mazut fuel oil. The weather was dry, yet in the middle of the road was an enormous puddle, a deep dark black. A forty-year-old woman in a pale pink dress stood near it. The theatricality of it all provoked me to pose her a question,“Ma'am, what should I do?”But she paid me no attention. I shouted,“What should I do?”“What to do, what to do?” she said in Polish. “Jump in the water and swim so far away that you cannot return.”I quickly crossed a section of the forest. The wind brought a mixture of unpleasant air, like a stinky handkerchief held under one's nose. Passing the trees, I saw light in the spaces between them and exited at the hospital.Outside the windows, two orderlies lay in chairs with their heads thrown back. Two others—fools—ran around the yard in different directions, peering out at... something. The lights on the first floor of the hospital were on, and the staff milled about.“You're just in time!” said Ivan, a tall, young orderly.“For what?”“Your patient ran away! We went into his room and he wasn't there.”“What patient?”“The one who bit Alevtyna,” said Danylo, the other orderly, short and middle-aged.“That's Skorsky's patient, not mine.”I had no intention of helping them. This was all history—like my family, Kyiv, and my previous life. I had no intention of thinking about it. I wanted to go to my office, pack up my field surgery kit, and get out. So what? Their psychotic syphilitic ran away—it happened.Of course, that patient could have something to do with Bilinsky's murder. But that was no longer my problem.“What a strange coincidence!” the doctor on duty said. “Comrade doctor, the other one responsible for this patient was just here.”“And where is he now?”“He took off toward the church to look for the patient.”“Didn't the patient escape earlier?”“Don't know.”“How do you not know? You had better call the police, moron, before he kills someone. And get those sleeping orderlies to look for him.”“They can't... ”“Why not? Should I go wake them?”“They're on morphine.”“And you, I can see, have lost your mind. Go, catch your psycho! If it turns out that he killed Bilinsky—and on your watch—you can't imagine what's in store for you.”I adjusted my homburg and set off in the direction of St. Cyril's, that unwelcoming monolithic cube. I glanced around—what if our escaped syphilitic were to jump out of the bushes and bite or strangle me. I looked around because I wasn't sure of my actions, wasn't sure of my choices. Tripping over a clump of clover, I reached the open doors of the church. I couldn't stop myself from going in.The walls and ceiling were covered with frescoes. There was what used to be an angel rolling up the sky on the southern column of the narthex. But also graffiti: people scratched their names on it so as not to be forgotten—their idea of eternity. Prince Volodymyr the Great compared this activity to the desecration of graves. The vandals paid a fine and were beaten with canes. During the raids of Batu Khan, the church was deserted and cracks appeared all over it. Wild martens and feral dogs sought shelter here; insects swarmed under the ceiling with its red mosaics. Birches grew in its midst. Water seeped in the cracks, the water became ice, the ice widened the cracks, more water seeped in the cracks, becoming more ice that further widened the cracks, the wall split and nearly fell over, and then the wall fell over. Yet the angel is still rolling up the sky... When I reached the exit, I heard a rustling behind me. I turned after I stepped outside: in the depths of the church, like a stick in a pot of tar, stood a man with a large bag thrown over his shoulder and a revolver pointed right at me.“Is that you, Doctor?“Don't move!”“What's... Skorsky, what's with you?”“Don't move, I say!”“What are you doing here?”And finally I understood... Skorsky was himself the psycho! (Really, I had known for a while.)“You are the murderer! I knew it! But—why?”“Shut up.”“It was you. You! The stolen cigarettes, the strange behavior, Bilinsky. If I shout, everybody will come running. They've already called the police!”There was heavy breathing behind me. And then a gun rang out.The city is overgrown with new buildings. They encircle everything that was once on the periphery. Kyiv has become an old lady that can no longer restrain herself in the face of pastries. The city climbs farther. It steps over the swamps, turns the old rivers into a series of lakes; the other bodies of water it drives into canals. The grain that falls from the wild wheat is black. When the sun heats it, the grain melts and trickles into the earth. St. Cyril's stands indestructible. No one spackles the small cracks in its walls with either expensive putty or glues, nor with cheap cement and whitewash. One day a small fox appears in the doorway. It runs inside and along the floor of simple gray tiles. The gods watch from the walls, watch and fall into ruin. The fox runs to the iconostasis. Before it is a time-darkened Virgin Mother and Child in oil on sheets of zinc. The fox runs the metal steps that wind up to the second floor. The fox runs past all the vaults, naves, all the frescoes. A buckthorn seed flies in through a broken window. It will be the first. Soon the buckthorn will grow everywhere. A dumb hare will make its nest in the buckthorn bushes and nightingales will settle in the upper branches to sing until the end of the world. The fox runs between the thick rays that penetrate the windows. It catches one of the rays, squints its eyes, and warms itself in the sun.The shot rang out, but I did not fall. I looked around—and on the church threshold was our syphilis patient bearing a rod. His head lay on the rocks by the doorway.“If only he'd been at the stage of nose deformity! Just imagine: a hole instead of a nose plus a hole from the bullet—like an extra pair of eyes!” Skorsky laughed at the corpse.“We need to call the orderlies.”“They heard the shot. They'll run here on their own. You see, Professor Bilinsky believed it would take two or three years to wrap up this patient's case,” Skorsky told me. “But I took care of it much faster!”“Excuse me, but I'm going crazy in this city. I thought that you were Bilinsky's murderer.”“Just so. Why not? I am Bilinsky's murderer.”“Don't tease. You've changed a lot recently, so... ”“Yes, I've started killing people. You might term such a change significant.”“You have the right to irony.”“I am not being ironic.”“Let's call it sarcasm.”“It's the honest-to-God truth.”“And yes, you have the right to mock me.”“Well then, let's be done. To the horses!”“What horses?”“Alina's waiting!”Alina, her uncle Skorsky, a few others I didn't know, and I rode like the wind that ripped off my homburg and carried it back to Kyiv.“There's a fresco in the choir loft at St. Cyril's where Vrubel painted himself and patients from the hospital as the apostles. When I came across it by accident, I really believed they were saints,” Alina said.“I've never been up there. I've only seen the church from below.”“Remember the way back so you can see it sometime.”“The Puchai River used to flow here. You shouldn't trust the landscape,” Skorsky said, reaching for something, perhaps his bag, just when we left the darkness of the trees and saw the endless steppe ahead of us.We rode all night without stopping. Though no one was chasing us. Though we had nowhere to be. We rode like beasts released from a cage. The promises of the horizon turned what we'd left behind into a cage fit for those from whom freedom had been severed, like an anomaly, at birth.The pre-morning sky looked at first like a sack of turnips—filled with something heavy. But with each verst, the sky became lighter. When it was finally light enough to see clearly, we arrived at a knoll at the foot of a stone wall that from a distance had appeared to be a gigantic piece of halva. The exterior ruins of the castle gave no hint of how it was when all was fine here, when people defended themselves successfully from the nomads’ raids. From far off, the wreckage looked like a natural agglomeration of stones—a rocky elevation, no more: a cluster of cliffs. It would rain a few hundred more times, a few hundred more winds from a few hundred directions would blow on this heap, and it would collapse as though nothing had ever been here.A few stalks of wheat grew from one of the rocks. Someone had probably cast a handful of grain here for some birds that forgot to eat it.“Who could this castle belong to?” I asked Skorsky.“I reckon the Swan Princess,” the doctor rejoined, hoping to sound knowledgeable.From behind one of the piles of gray sandstone emerged a young man in a black reptilian coat and a white papakha as lush, bright, and out of place as a dahlia. His name was Artem. The heat was melting our brains, but he was dressed like that, in rooster fashion, which was popular among the otamans. Artem helped Alina dismount her horse and tried to kiss her on the lips, but she offered him a cheek instead.Had she been racing to see this clown?We entered the yard—the ruins had fashioned an internal space that was more or less protected, at least from strangers’ eyes. It turned out that there were even places where it was possible to hide from the rain, and from there the ruins didn't look half bad.In the center of the court was a table, and on it a wooden bucket with pink gladiolas. How romantic! It all looked like it came from outer space. Where on earth, in the middle of the steppe, far from any village or town, did this table, this simple table, come from? And the gladiolas? The steppe hadn't been plowed in so long that any cultivars would have gone wild, degenerated, dried up completely.A campfire crackled nearby—a little preview of what we would soon do to the houses, villages, and cities. Artem the otaman brought over a cezve from the fire and poured the first portion into a small, copper cup for Alina. He also got out a porcelain cup with images of rosy cherubim—but how...?“Who else would like coffee?”Only Skorsky and I responded. The question excited me, even distracted me from the thought of the kiss I had recently witnessed and the Kyiv I had recently left.“It's obvious who the professors here are; cultured people drink coffee. Are you both doctors?”“Uh-huh.”“For wolves of the steppe, like us, doctors are gold, even more precious than gold. Actually, a Hippocrates like you should eat more, because those in your profession will soon be worth your weight in gold. Work on your figures, both of you.”“Who will take pity on the horses that have to carry us?”“We'll find the horses. And very large doctors can be transported on machine-gun carts. We'll need to seat the otamans near you. Only a fool would shoot at a doctor.”“I think we'll find quite enough fools here.”“With your beard, Doctor, you look like Tsar Nicholas II. But even so you won't be shot. You might even be canonized!”“We've only just arrived and you're going on about executions,” Skorsky grumbled and checked to make sure that he still had his bag.“Apologies, apologies, pardonnez-moi. But you are not merely a doctor. A venereologist! Skorsky, you're a specialist! A venereologist is the most important person in wartime. The most valuable! You are the botanists of war. You can't imagine what varieties of flowers grow here, and these beds have long awaited a proper gardener. Or even just a man with a scythe!”“Bite your tongue,” Alina said. “I don't need to listen to this.”“Yes, yes, of course. Excuse me, my r—. ” He almost said “rose.”We rested all day. We went down to a surprisingly close river overgrown with lilies. We rowed the boats left by fishermen. I talked to Skorsky. He took his bag everywhere, refusing even to swim so he wouldn't have to part with it. I asked him what he had in it, but he said it wasn't my damned business.Alina rowed with the otaman to the middle of the river. They were having a loud discussion. She was waving her hands. The current carried their boat downstream slowly and smoothly. What a nuisance, that current!I tried to meet with Alina one-on-one, but she was avoiding me. In the morning I was confused, by lunch I was sad, and after lunch I got angry.In the evening, I lay on the hot grass and drank another cup (I have no idea where they got such good coffee), which had no effect at all on my sleep. I watched the Perseids. Every year, the Earth passes through the tail of Comet Swift-Tuttle. People can see the meteor shower and make a wish. I wished. I counted forty-seven falling stars. All forty-seven of my wishes were for the same thing.Around the campfire, they were sitting, talking. I saw how he tickled her face with a piece of grass and she brushed him off in annoyance. Then they were screaming at each other. Later they again spoke kindly, after which they again quarreled. My joy grew after each tiny mistake that Artem made. I wanted him to show the worst he was capable of.They were screaming at each other, but all I could hear was beautiful opera singing. The stars fell to the sound of their screaming. The stars blessed my joy.Then this happened: Alina kicked the fire, scattered burnt kindling, and burned some of the grass. Artem grabbed her by the arm, but she broke away from him and ran off to the horses.“Go then! I guarantee you'll get to Katerynoslav and return with your tail between your legs.”“I'm going to Huliai-Pole! To Father Makhno!”I jumped up and ran after her.“Where do you think you're going?” Artem shouted.Really—where was I going? I was going after her: to Huliai-Pole, to Katerynoslav, to Rome, to Washington, to Istanbul, to Montevideo... “Go to sleep,” he said. “Come morning, this coquette will be here, right as rain. We've already been through this show. Tomorrow she'll be right here next to my boot!”... No, she won't.In some sort of shape we entered some town. There were some buildings that were some colors, some trees, some streets, some roads, and some signs. Posts, flustered birds’ nests, echoes, colors, shapes—each of some kind. A wedding procession was coming toward us. If you want to make orange, you need to add yellow to red, and then bam—it's black. If you want to salt the soup, shake in a little, and then bam—two handfuls. You want to say a kind word, and then bam—a punch in the face. I was rocked around like a watermelon on a boat and threw up my breakfast straight into the horse's fluffy mane. Sanko found this hilarious, but I said I'd pulverize him. So Sanko sped ahead.No one knew anything about Alina. The daytime sky was like a poorly washed bowl. The sun was a squashed, rotten apricot. The night sky looked like the sole of a boot to me. The moon was a dirty cheap copper coin that had gotten stuck to the sole. Everything seemed spoiled to me, irrelevant, unnecessary. Without her, this journey was a waste of time.“You'd better stay away from everyone,” Artem said. “You'll infect us with your pining, and pining is worse than the clap.”The wedding procession was before us. The young couple, still utter children, walked so calmly it was as if they didn't see us. As if we were made of a light breeze—our bodies, clothes, our horses and their iron shoes—of the lightest gasses. As if we were visible only to ourselves and the coal-black dog that barked, panting and gasping.The wedding was headed straight for us. We were in the middle of the road, and so were they. We approached each other slowly, a wave going toward a wave. Some ten meters before their indifferent faces, I noticed the color of the bride's eyes. And the coral-colored tulips that fell on the road before her. Round goose eggs on meaty stems, the flowers were falling and falling before her. The bride's eyes were almond shaped.“Hey there,” Artem shouted at me. “Wake up!”I came to and saw the whole village, everyone there, not realizing my group had turned left onto a side street away from the procession. The tulips disappeared—where'd they get tulips in the fall? I was sitting alone on my horse in the middle of the road, and the entire wedding procession came to a stop. I moved to the side, and the throng marched on, cutting off our escape route. We rode a few more meters and came across the synagogue.“You know what, you're right,” said the otaman.“Who is?”“Oleksii is the only one here who's right.”“About what?”Artem turned his horse and raced back. Everyone stood still while he ran his horse into the crowd and began firing his revolver. People scattered in all directions. Artem trotted, cackling like an imbecile. The horse kicked an old guy in the mouth. The man fell, spitting out his gold teeth. We rode up to the commotion and formed ranks, but none of us wanted to join the otaman.The bride stopped in the middle of the street. On both sides were buildings and trees, as well as dust, sky, and sun. She stood still, beautiful, as if nothing had happened. Then she adjusted her garland and walked calmly on.“Well, should we get some sugar now?” Artem laughed, looking at the bride, and off he went toward the sugar factory.It was then I noticed that all of the houses had shutters—fuchsia, blue, ocher—and that all the shutters were closed.We flew toward the dirty building, whistling and shouting. If there had been aesthetes among the otamans, they would certainly have razed the abomination in this field after seizing it. They would have spread soil on top and sown buckwheat. Long live buckwheat!, that wonderful crop. Like hunting dogs hot on the trail, we raced to our defenseless victim, with the baying of hundreds of hounds behind us. The field shook beneath us. We became an artist's canvas, evolving from Realism to Romanticism, Romanticism to Expressionism, Expressionism to Suprematism. If we had been painted in black and white, we would have been splotches (until the ink ran, annihilating all remaining patches of white).Two men stood near the gate—unarmed and undressed, in nothing but their undershirts and boots. Our fervor, our kinship with the elements, our entirety, were all for naught.“Jesus Christ! What bores!” Artem exclaimed. “How boring you are!”“Maybe boring for us, but fireworks for them,” Sanko said, dismounting his horse.“The fear of death engenders creativity,” our otaman—a distinguished philosopher of the early twentieth century, that demonic breed—prophesied.He went on, “Excuse me, but with all due respect, we are not going to search you. Just show us right away where the money is. Why are there so few of you? Don't say there's not much money. I want piles and piles of money! If you don't show it to us, we'll print our own on your skin. Believe me, we will.”We entered the factory grounds. There were no workers, only an enormous mountain of sugar beets that looked like a pile of coal from a distance and a pile of dead rats from up close.“So, did you have a good year?” Artem asked a man in an undershirt.“Not really—too dry.”“Nah, that's fine. You wouldn't have been able to gather most of the harvest this year anyway. There's a fire burning across all of Ukraine, all of Russia. The whole world!”While Artem tossed thoughts like well-chewed sunflower seeds into the crowd, the two men quietly stepped aside and then ran fast ahead to the factory's main hall. The gigantic door slammed shut. The gate was locked behind us! The windows were smashed! The factory roared from inside like a cumbersome machine starting up. Bullets whirred through every window.“Bastards! It's a trap! Quick, after me!”Still on horseback, Artem bounded over to a vast window, low to the ground, and smashed it mercilessly. He broke the frame and jumped inside on his horse. I and a few others followed. We broke into their lair, threw open the doors, and let the other warriors inside.Iron vats of hot sugar were steaming, pipes were clattering; machinery groaned.“Parasites!” Artem gritted his teeth. “I'll get you. I'll get you red sons of bitches. Painted whores!”At the word “painted,” his horse fell to the ground. Lying prone, Artem continued fighting, but the red soldiers wouldn't let him stand. Fighting nearby, I rode over to assist but did not know where to aim. Artem got up, ran forward, and brought his sword down on the head of the closest soldier, all the way to the middle of his skull, to the bridge of his nose. It was like butchering a pig. Artem thrust the sword into the buttock of another who was fleeing and cut off his leg at the bend in the knee.“I'll cut off every last one of your asses! Cut off your asses!” Artem bellowed.A half hour later, the dead were lying, the captured sitting, and the victors doing anything they pleased.“Skorsky, are there a lot of casualties?” I asked the doctor, whose hour it was. I hoped not, because I was too tired to help him.“Just a few. The dead are already dead, and the wounded are not ours.”Though Skorsky rarely asked my help, and though I'd become an ordinary soldier, the doctor in me was still present in the most unpleasant attribute—knowledge. Others saw an eviscerated man, pieces of dusty flesh smeared with clay, soil, sand, and straw. I saw a perfectly formed kidney hanging perfectly from the rest of its body like a child's mitten from its coat. You could try this death on for size. Wear it like a sanbenito of the Inquisition.Artem counted the money and then lay on the floor alongside the gigantic sugar mountain in the middle of the room. From time to time, the crystals rustled as they fell.“I didn't think you'd be such a fighter!” the otaman said without turning toward me. “I thought you'd be healing us. You'd keep to the rear and we'd hide you like a girl. But here you are, in the vanguard, like a lion!”“I got excited,” I told him, choosing not to react to the “girl” part.“’Cause Alina said there was no sense counting on you to fight.”“Really?”“Does that sting?”“Why would it? I'm a doctor—not everyone is. It requires a brain. Unlike waving a sword.”“Yeah, yeah. I gave her gladiolas. We were lying in the boat near that castle, doing all manner of things, and she told me all about you. How you met.”“You were lying in that boat talking about me?”“It was the day before you left Kyiv. You agreed to go with the anarchists so quickly!”“Were you surprised? Doctors make fast decisions.”“But you probably had great prospects. Your parents are rich, right?”“And who are your parents?”“Probably all your relatives fled abroad—bourgeois. Why did you stay?”“What the hell's your point?”“Alina, by the way, died a while ago. Probably.”“Don't jinx her.”“Listen here,” he said, staring at the ceiling. “And listen good. If you have designs on her—dead or alive—it's best you castrate yourself now.”“After you.”“If I want to kill somebody, you know, I just do it.”At last he looked at me. I was lying on the floor nearby and looking in his direction, sweaty and relaxed, my appearance complemented by my disdain for his opinion, his authority, his stupid hat. His everything.Artem raised his arm above his head, stuck a finger in the sugar mountain, and licked it. We both got up. Had I anticipated this turn of events, I would have readied a gift for him. Artem held his revolver. Under my hand I found a knife the workers used for gathering beets: it was a deliberately sharpened arc they sank into the swollen brassicas. I jumped up and quickly stepped around the sugar mountain.Artem's bullet hit a pane and broke the glass.“Not man enough for hand-to-hand?”The otaman shot again.“You should've challenged me to a duel, you romantic!”Encrusted with white crystals, I charged Artem from the sugar mountain. We fell in, and the sugar stuck in our hair, mustaches, nostrils, armpits.The gang ran in to get us apart, then backed off because it had nothing to do with them. By now the sugar mountain had burst its banks. Of the once perfect pyramid, a deformed mound remained.Wounded, Artem fell on the sugar mound, turning the white red.I stood before the gang sugar-coated and holding a bloody hook. The old otaman was drawing his last breath. Blood trickled from the corner of Artem's mouth and streamed from the left side of his breast.“What's the commotion?” Old Roman had just come in.“Be quiet,” the boys told him. And a good thing they did.“You killed him? You killed the otaman!”“Shut your mouth,” the boys told him.“You... ”I slugged Roman's stinky herring mouth. How did that son of a bitch find pickled herring in a sugar factory? My fist was now bigger and stronger than ever before, a steel anvil that could split nails and shatter memorial plaques. The unfortunate man's jaw twisted like an upper millstone that had gone off track from the lower.“Let's get out of here and go to Makhno's camp,” I gave my first order.We galloped so fast the grass burned beneath us. The birds and bugs had no time to fly out of the way; hooves trampled the burrows of rodents who didn't dare crawl out of their holes for a long time after. We raced like no one had ever raced before.The steppe, that sly fox, pretended to be an innocent fool. The steppe said, “I'm like Adam: I don't even know my own name.” But its grass harbored the tracks of thousands of armies and the heels of Herodotus, the crunch of Trypillia vessels, and the smell of Scythian hemp, Roman coins, clay figures of wolf people, the chevrons of Denikin's army, glass from the Chekists’ ruby stars, traces of uranium from flying saucers. I threatened it: “Steppe, show me your layers, or I will burn you, plow you under, flood you.” But it just replied: “I'm like Adam: I don't yet know my name.”I lost geography as if it were a silver coin. It fell out of my pocket and rolled through the feather grass that blanketed the steppe in white foam. The open space ahead was so endless that the whole world might as well have been steppe. If people ended up here from somewhere else, they would conclude they were on another planet. The coin fell and became an argentum, became one with the ring on the hand of the princess who had one green eye and one blue, with the twisted candlestick at the monastery on the other side of the steppe, with melted ingots. It broke down into simpler elements, simpler and simpler yet. The horse carried me spreading the seeds of northern plants to the south, just as southern riders had once brought flowers and weeds to the north. And then I turned back. Just as I had no geography, I had no time. Every night I fell asleep with the thought that the next day I would again race. Through all spacelessness, all timelessness. I exchanged one horse for another, got on a train, on a boat, traversed forty versts on foot—in rain that brought the river up to the road, in heat that overturned cattle. The earth I walked on became mine. Mine was the water in the lakes and springs, clean water, dirty water, enlightened water, contaminated with oil, stinking of algae, of fish that died in wells, stinking of the memory of atrocities, water as clean as broken bread. The water did not become Alina.I was doing this for her: I got the basturma out from under my saddle, sodden with the horse's sweat, sliced the throat of a rich man whose daughter I had danced with at a ball, climbed into a vat of beet juice and took a sugar bath, carried out the expropriation of the savings banks, wiped the sweat from my face with my shirt—and the cloth turned red; I didn't know from what. If it was someone else's blood, I didn't care; if it was my own, even less.We mostly came across Reds. We scraped them up like old red paint on a door in order to repaint the boards black. Black looked better. Red is tasteless, but black has style. Healthy men died before us of myocardial rupture like bunnies found in the nest. The ones whose hearts were sewn of steel wire envied the deceased. Seizing estates, banks, distilleries, and prisons reminded us of gathering in the harvest. If you're too lazy to pick an apple, you can shake the tree; some of the fruit gets bruised when it falls. We seized buildings like we were shaking apple trees. No one picked the fruits, we just shook: shook under the beds, under the tables, behind the curtains. No, there was no picking. We just shook until the red juice spurted from the apples.Near the Khorol River with Father Makhno and me in charge, we captured sixteen machine guns and four cannons, as well as five hundred prisoners who immediately came over to our side. The villagers voluntarily gave us bread and cheese, chickens and kvas. People joined us. The front of the machine-gun cart said “You can't run,” and “You won't catch us” at the back. We took factory after factory. Millions of karbovantsi, thousands of poods of sugar, weapons. We smashed the telephone exchanges and captured the telegraphs. We made alliances with some and then with others. Lenin, Wrangel, Frunze, the Germans, Chinese, Australians, Kaiser Wilhelm II, Cleopatra, Maria Theresa Walburga Amalia Christina. We ran the steppe. There were a hundred thousand of us. There were three hundred thousand of them. There were three hundred thousand of us. There were a million of them. There were two million of them. We were all of humanity. We were so many that we were none.The nobles’ estates were long ago forsaken. In the people's deepest trunks lay silks and guipure laces that were once perhaps used only to cover a table. Five steps from the barn in the direction of the pear tree, some silver candlesticks are buried; there's a plaster figure of an angel in the chicken coop, covered with shit and feathers.I was reluctant to be going to my home, but I didn't see any way out. Fate intended me to be a different being from the one I was before.Here my grandfathers and great-grandfathers were born. Here the ones who caused my grandfathers and great-grandfathers to flee had stopped. When we were still far off I noticed that someone was in the house. It was our men—Skorsky had brought them here, about twenty in all. I asked Sanko, whom I had walked with side by side more than once, where the doctor was now. All the men answered that he was around somewhere, but I didn't see him that evening.In 1918, the spirit of my great-grandfather Stepan, along with my mother and uncle, had gotten into a britzka and scrambled off to Paris, to Napoleon, against whom my great-grandfather had fought with the Cossacks, to whom the Russians promised to return self-rule. Following him in the cart went the soul of Grandpa Oleh, who lost a finger when he cut down the old linden near the house; his second finger was blown off by a cannonball near Balaklava, and later his entire hand was cut off by some Turk. Next went the spirit of my father, also Stepan, who did not take part in any war but died of measles at the age of forty. They all got the hell out of here. First, they went to Kyiv, led by my mother, Tamara Makarivna, in order to collect Uncle's family and me, their son. And their son, it turns out, has now come back to rob his own home (I didn't drive my war buddies away, did I?). It's a shame that I didn't know where the bathtub was, or whatever they bathed me in when I was small. It would have been good to walk through the ranks of anarchists with that basin and tell them all to spit into it.Remembering every room, I carried Alina upstairs to my mother's bedchamber. There was no longer furniture or pictures, only bare walls. The bed and mattress remained, but that was enough. Mother hated noise, so she set up her room far away from the running in the halls and the creaks on the stairs. I adjusted the mattress; in a gap, looking like a stalk of wheat, there lay a gold bracelet that she lost in the haste and that the thieves could not find in the mayhem. I tucked it into my pocket.The place could still be saved. It was strong, built under the leadership of my grandfather, who knew how to do it right. He built a sawmill, a gristmill, a dress factory (today it's probably been ransacked, maybe even by our own men).Alina had a complete, displaced break in her right fibula. We needed water first. I went downstairs—the guys were dragging out the piano like an old cow to the slaughter.“What are you doing with that?”“Taking it out.”“Why?”“What's it to you? We want to have fun.”“Can you play?”“We're not your bourgeois lily-handed bitches.”They couldn't play, but they were famous at destruction. “Noise is the music of the new time,” one of the smarter among them might have said. “But noise is the opposite of music. Just as a rose is the opposite of your ugly mugs,” I'd have responded if there was anyone to say it to. I could also have said that this was a Bosendorfer grand piano, that it was very valuable—but do the guys not deserve such a luxury?“Why are you so boring? We're relaxing.”“Then let me play a little first.”“Go ahead, but fast. One-two.”So I played. As before. My fingers ran up and down the black and white keys, which weren't simply keys of these, the simplest, colors. These were the keys that remembered my fingers specifically—achieved by that slovenly German Katerina, our governess. She knew a bundle of languages, could play the piano, and was interested in the latest scientific discoveries. But she had not an ounce of sympathy for anyone who couldn't master anything on the first try. More than once she hit my pinkie against the black key that remembered every one of its four thousand touches. She would pound it on the key and shout, “Si bémol! Si bémol,” and later bang my fingers and translate, “B flach! B flach!”I played. I could not expose myself, so the only thing I could do was believe in miracles. What if these coarse men saw value in this bit of furniture so unintelligible to them? And what if they didn't destroy it, this emblem of my childhood, my land, my air, which I could protect in no other way? My air. My water.“Shchedryk, shchedryk, shchedrivochka,” one of them who recognized the tune began to sing along.“Look at you.” They did not expect music from me, who had until recently been drinking blood like water.They said, “Again, again!”A group of curious men gathered around me. They were ordinary farmers, thieves, and recidivists, peasants and workers, everyone except for Skorsky. They needed this music as they needed baths. The music cleansed them from the inside, perhaps. They had not heard anything besides the whistle of a bullet, the neighing of a horse, or the knocking of a chisel and the whirring of a saw, amputating limbs, for a long time.But it could not go on long. I did not close the piano lid, just stood and went to fetch water for Alina, leaving the unfinished song for later. The well was to the north—that is, at the “Head.” My father once promised to give me a compass if I could learn to identify the ends of the earth by means of the sun. And to make it easier to remember, I gave each one of them a name: the east where the day begins was “Right” (my right hand), the west “Left,” the north “Head,” and the south “Feet.” Back when I could still do whatever I wanted all day long, I would wake in the morning and say: I'm going to the Feet. The mound was at the Feet, Left had the river, Right had the forest. It was only to the Head that I rarely went, because a village was located there. When the villagers saw me, they would speak in whispers and avoid the master's son.... I wiped her brow and her burning, sunken cheeks. I lay down next to her to feel the heat of her skin.When the fire in Alina calmed slightly, I went out into our orchard. My father had once been given a gift from Japan—a tulip tree that blossomed with yellow-green flowers. It had to have grown in the time that I was away. It would have been fatal had it been cut down. I again took the stairs down into the drawing room and came across nobody—they had all disappeared in search of food or were hidden away in their burrows. In the middle of the hall, like an opened rib cage, was the piano, irreparably shattered.B Flach! B Flach!Translation © Ali Kinsella 2022. (shrink)

Background and purposeThis study aimed to analyze the feasibility and safety of endovascular therapy (EVT) in patients with acute posterior circulation stroke and vertebrobasilar dolichoectasia (VBD).Materials and methodsBASILAR was a national prospective registry of consecutive patients with symptomatic and imaging-confirmed acute stroke in the posterior circulation within 24 h of symptom onset. We evaluated EVT feasibility and safety in patients with VBD. Primary outcomes included improvement in modified Rankin Scale scores (mRS) at 90 days and mortality within 90 (...) days. The secondary outcome was the rate of favorable functional outcome, defined as mRS ≤ 3 (indicating independent ambulation) at 90 days. Safety outcomes included surgery-related complications and other serious adverse events.ResultsA total of 534 cases were included: 159 with VBD and 375 controls. No significant difference in mRS at 90 days was found between groups, but patients with VBD had a higher baseline National Institutes of Health Stroke Scale (NIHSS) score [30 (19–33) vs. 25 (15–32)] and were older [65 (59–74) vs. 63 (55–72) year]. After propensity score matching, there were no significant differences in baseline NIHSS score between the two groups, and the efficacy and safety of EVT were similar between patients with or without VBD. Furthermore, the prognostic effect of puncture-to-recanalization time on the probability of mortality within 90 days in EVT-treated patients with VBD was significant {adjusted odds ratio, 1.008 [95% confidence interval (1.001–1.015)]}.ConclusionEndovascular therapy is safe and feasible in patients with acute posterior circulation stroke and VBD. The puncture-to-recanalization time is important for predicting the prognosis of EVT-treated patients with VBD. (shrink)

The COVID-19 pandemic hit healthcare professionals (HCPs) hard, potentially leading to mental health deterioration. This longitudinal study investigated the 1-year evolution of psychological health of acute care HCPs during the COVID-19 pandemic and explored possible differences between high and low resilient HCPs. From April 2020 to April 2021, a convenience sample of 520 multinational HCPs completed an online survey every 3 months, up to five times. We used mixed linear models to examine the association between resilience and the variation (...) of COVID-19-related anxiety, depressiveness, perceived vulnerability, and psychological trauma symptomatology. We demonstrated “u-shaped” trajectories for all mental health symptoms. We also explored differences in the abovementioned variables between front-line and second-line acute care HCPs. In contrast to HCP.s with lower levels of resilience (-1SD), those with higher levels of resilience (+1SD) showed increased COVID-19 anxiety and perceived vulnerability over time. Front-line and second-line HCPs differed in their depressiveness and psychological trauma variation during the 1-year analysis. High and average resilient second-line HCPs showed steeper depressiveness increases with time than high and average resilient front-line HCPs. Acute care HCPs reported their most elevated clinical symptoms of depressiveness (5–7%) and psychological trauma symptomatology (26–46%) in April 2020. During the first year of the COVID-19 pandemic, second-line HCPs with more resilience showed a steeper worsening of their depressiveness than more resilient front-line HCPs. HCPs with low resilience may benefit from interventions at the beginning of a pandemic, whereas HCPs with high resilience might benefit from resilience-enhancing interventions at later phases.Trial RegistrationThe study protocol was pre-registered with the International Standard Randomised Controlled Trial Number (ISRCTN13694948) published (Fuchs et al., 2020). (shrink)

In the past decade, the availability of genetically modified animals has enabled the discovery of interesting roles for phosphatidylinositol 3‐kinase‐γ (PI3Kγ) and ‐δ (PI3Kδ) in different cell types orchestrating innate and adaptive immune responses. Therefore, these PI3K isoforms appear to be attractive drug targets for the treatment of diseases caused by unrestrained immune reactions. Currently, pharmacological targeting of PI3Kγ and/or PI3Kδ represents one of the most promising challenges for companies interested in the development of novel safe treatments for inflammatory diseases. (...) In this review we provide a general outline of PI3Kγ‐ and PI3Kδ‐specific functions in distinct subsets of inflammatory cells. We also discuss the therapeutic impact of novel compounds targeting PI3Kγ, PI3Kδ or both, in mouse models of autoimmune disorders (systemic lupus erythematosus (SLE) and rheumatoid arthritis), respiratory diseases (allergic asthma and chronic obstructive pulmonary disease) and cardiovascular dysfunctions (atherosclerosis and myocardial infarction). (shrink)

While outcomes for children with T-cell acute lymphoblastic leukemia have improved dramatically, survival rates for patients with relapsed/refractory disease remain dismal. Prior studies indicate that glucocorticoid resistance is more common than resistance to other chemotherapies at relapse. In addition, failure to clear peripheral blasts during a prednisone prophase correlates with an elevated risk of relapse in newly diagnosed patients. Here we show that intrinsic GC resistance is present at diagnosis in early thymic precursor T-ALLs as well as in a (...) subset of non-ETP T-ALLs. GC-resistant non-ETP T-ALLs are characterized by strong induction of JAK/STAT signaling in response to interleukin-7 stimulation. Removing IL7 or inhibiting JAK/STAT signaling sensitizes these T-ALLs, and a subset of ETP T-ALLs, to GCs. The combination of the GC dexamethasone and the JAK1/2 inhibitor ruxolitinib altered the balance between pro- and anti-apoptotic factors in samples with IL7-dependent GC resistance, but not in samples with IL7-independent GC resistance. Together, these data suggest that the addition of ruxolitinib or other inhibitors of IL7 receptor/JAK/STAT signaling may enhance the efficacy of GCs in a biologically defined subset of T-ALL.Leukemia advance online publication, 30 May 2017; doi:10.1038/leu.2017.136. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Call for New Theological Reflection on the Sacramental Character of Marriage and the Thought of St. ThomasLawrence J. WelchTheologians across the theological spectrum have called attention to the urgent need for a new reflection on the theological and sacramental character of marriage. Peter Hünermann, known for his strong criticism of magisterial teachings on marriage, and the late Cardinal Carlo Caffarra, known for his equally strong defense of them, (...) have both drawn attention to this need. At an international symposium in September 2015, held in Rome prior to the Ordinary Synod of Bishops on Marriage and the Family, Hünermann gave a presentation entitled "On the Specific Theological Character of the Sacrament of Matrimony."1 The symposium aimed at providing a critical and scholarly discussion of new and constructive perspectives for the Church doctrine on marriage and family life in time for the 2015 synod on the family.2 Some of Hünermann's work from this paper also came to be known from an interview in Commonweal magazine where he summarized some of the main points of his symposium presentation.3 In the interview, he also revealed that before the 2015 synod he [End Page 845] was invited to speak with Pope Francis about the theology of marriage. Understandably, this meeting heightened interest in the German theologian's thought.Hünermann argues that "the specific character of the sacrament of marriage, which is very closely connected to the dying of the marriage bond,... has scarcely been the object of theological reflection, [and] is almost unknown in the consciousness of the bishops." 4 Hünermann appeals to St. Thomas as a way forward for understanding the theological character of marriage. This appeal is situated within a wider examination5 that offers an elaboration and new interpretation of "the specific dogmatic characteristics of the sacrament of matrimony that emerge in today's situation from a critical comparison of the encyclical Casti connubii and the Catholic theological tradition, especially the theology of St. Thomas."6 Sharply critical of the encyclical, Hünermann sees it as having saddled the Church with a legalistic concept of marriage elevated above history that is too far removed from the Catholic theological tradition and St. Thomas's theology of marriage.The year before his death, Cardinal Caffarra gave the 2016 graduation address at the John Paul II Institute for Marriage and Family in Washington, DC.7 Among the challenges he identified for the institute to address was the [End Page 846] need for theological reflection on the sacramental character of marriage. Referring to his earlier work, he pointed out that theology after the Council of Trent "lost the awareness of sacramental ontology, of the real transformation produced by the sacrament in the persons of the spouses [res et sacramentum]."8 Furthermore, according to Caffarra, the "theology of the conjugal covenant was supplanted by the notion of a contract, as a human act by which two persons commit to one another." The sacramental character was thought of as consisting of the assurance of divine graces given to fulfill the contract. Caffarra claimed that, "consequently, the words of Jesus 'What God has joined together, let not man put asunder,' lost all their realistic force. Absolute indissolubility, once the sacrament was perfected [=a ratified, consummated marriage], became essentially indefensible."9The primary interest of this paper is to respond to the call for a renewed theological reflection on the specific character of the sacrament of marriage. I wish to take up Caffarra's suggestion to focus on the sacramental character (res et sacramentum) on the one hand, and on the other hand, Hünermann's suggestion that a kind of ressourcement from St. Thomas Aquinas's theology of marriage can be of great help for a fresh theological reflection on the specific character of the sacrament of marriage. Although I agree with Hünermann that a renewed consideration of the thought of St. Thomas can be a way forward, I differ from him on how it can be. Hünermann notices that St. Thomas speaks of the grace of the sacrament of marriage as a helping grace.10 St. Thomas does indeed speak this way of the... (shrink)

With the high frequency and intensity of worldwide disasters, cause-related marketing campaigns with sudden disasters are becoming increasingly popular. However, little is known about whether and how cause acuteness may influence consumer attitudes. This research aims to extend this research area through investigating the relationship between cause acuteness and consumer attitudes toward the product, as well as its underlying mechanism and boundary conditions. Based on a moral psychology perspective, we propose a theoretical model focusing on the mediating role of moral (...) elevation in influencing consumer attitudes. This model also incorporates product-cause fit and information transparency as moderators underpinning necessary conditions that are likely to lead to positive consumer attitudes. Four empirical studies were conducted to test our model. Our research results reveal that consumers have more positive attitudes toward the product associated with a sudden disaster than with an ongoing tragedy. Furthermore, the positive effect of cause acuteness on consumer attitudes is mediated by enhanced moral elevation, which occurs under the conditions of high product-cause fit and high information transparency. (shrink)

For all its originality and traditional wisdom the metaphysics of a thirteenth century Aristotelian Christian comes in a remote idiom to the current secularist mind, even though this be conscious or semi-conscious of the ambiguous epistemological and ethical presuppositions respectively of its scientific method and practical living. The problem of presenting its achievement in appealing contemporary guise remains acute and fluid. The usual, direct solution is adopted here in personal fashion by Father Reith, who states his modest terms of (...) reference as follows: “It is not my intention to write an apology for the metaphysics of St. Thomas. His philosophy is its own best apology…. The present book is an attempt to restate as accurately as possible, in the manner and sequence found in the writings of St. Thomas, those metaphysical principles that have become the natural foundations upon which our contemporary Christian philosophy has been built”. If this system of thought seems formidably doctrinal to the rootless positivist, its questions refuse to leave him in peace: those human questions which concern ultimate truth in reality as a whole, in particular man’s own social and physical order in the universe—his origin, value and destiny, the reality of the laws, moral and positive, which his practice implicitly accepts—whose roots should be critically inspected and explained by some one at some time, for his own speculative benefit and for that of others. (shrink)

La contribution se propose de mettre en évidence les problèmes épistémologiques et méthodologiques posés par l’annotation discursive de productions écrites d’élèves et les choix techniques qu’implique sa mise en œuvre. Dans un premier temps, l’article montre l’intérêt scientifique de la constitution de « grands » corpus scolaires rassemblant plusieurs centaines de textes d’élèves d’école primaire et de collège de niveaux scolaires différents répondant à une même consigne. L’unicité de la consigne permet de comparer les productions en vue d’élaborer une cartographie (...) des moyens linguistiques choisis par les élèves et de mettre en évidence des indicateurs de progressivité. Dans un second temps, sont présentés les enseignements tirés de l’expérience d’annotation discursive qui a abouti à la création de la ressource ANNODIS, corpus de textes en français écrit standard annoté discursivement. Elle s’interroge sur les adaptations nécessaires pour traiter des textes d’élèves et définit des principes de travail généraux notamment sur le choix de la version de texte à annoter, la définition du modèle d’annotation et les guides d’annotation. Sont ensuite exposés deux chantiers d’annotation portant sur des textes d’élèves de fin d’école primaire en réponse à une consigne mettant en jeu la cohésion textuelle, qui demande d’insérer dans un texte narratif trois phrases comportant des pronoms et des syntagmes nominaux anaphoriques. Les notions sont illustrées par l’analyse de deux textes d’élèves de 5° Primaire. L’annotation des Relations de Discours procède successivement, dans une démarche proche de celle d’Annodis, par segmentation du texte en Unités de Discours Élémentaires, analyse de la cohérence temporelle et annotation des Relations de discours. L’annotation des chaînes de référence dans les textes d’élèves suppose des adaptations plus importantes du guide d’annotation antérieurement élaboré. Les premiers essais permettent ainsi de définir des principes de travail pour l’annotation des textes d’élèves. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:The Rhetoric of St. Augustine of Hippo: "De Doctrina Christiana" and the Search for a Distinctly Christian RhetoricCalvin L. TroupThe Rhetoric of St. Augustine of Hippo: "De Doctrina Christiana" and the Search for a Distinctly Christian Rhetoric by Ed. Richard Leo Enos and Roger Thompson Waco, TX: Baylor University Press, 2008. Pp. 420. $44.95, paperback.Is De doctrina christiana (DDC), by Saint Augustine, bishop of Hippo, a narrow appropriation (...) of the rhetorical tradition to serve the limited purposes of sectarian religion? Or does DDC extend and expand the rhetorical tradition in a transitional historical moment? One is often led to different conclusions when reading about Augustine than when actually reading Augustine, even in translation. The Rhetoric of St. Augustine of Hippo: "De Doctrina Christiana" and the Search for a Distinctly Christian Rhetoric offers students of rhetoric an opportunity to do both: to read Augustine, in Latin and in English translation and to locate Augustine definitively within the scholarly tradition of rhetoric and philosophy. The volume offers formative essays by Charles Sears Baldwin and James J. Murphy, introduces basic arguments about how Augustine's rhetoric emerged amid the turbulence of the late Roman Empire through the work of Ernest Fortin and Michael Leff, and offers more recent engagements with DDC in essays by Gerard Watson, David W. Tracy, and John D. Schaeffer. However, what makes the volume indispensable for students of philosophy [End Page 86] and rhetoric is the reproduction of the complete work of Sister Theresa Sullivan on DDC, book IV (DDC IV)—the Latin text, her translation, her notes, and the front matter of her original version (Sullivan's English translation and notes were anthologized in both the first and second editions of The Rhetorical Tradition: Readings from Classical Times to the Present, edited by Patricia Bizzell and Bruce Hezberg).Every generation needs examples of good scholarship that does not take shortcuts. Sullivan's work captures the careful craft of close work with an ancient text. Thanks to Enos and Thompson et al., Sullivan's impressive scholarship anchors this fine volume. I first review Sullivan's contributions in the book, then comment briefly on the essays that contextualize her work within the broader sphere of rhetorical scholarship on DDC IV. Why is Sullivan's work indispensible? First, the Latin text set beside the translation is unique to English translations of DDC IV currently in print. The quality of Sullivan's translation is evident. The Latin text also reminds us to consider the text as it might sound to Latin/Roman ears and foregrounds the enigmatic process of translating an ancient, complex text. Second, the commentary elevates the significance of DDC for philosophy and rhetoric. Sullivan dispenses with a great deal of nonsense about DDC in a few simple lines. For example, she demonstrates Augustine's deep knowledge and reliance on a broad spectrum of the received philosophical tradition in rhetoric. The notes correlate Augustine with Cicero in ways obvious in the Latin but opaque in translation and similarly show how DDC IV incorporates rhetorical theory from Aristotle, the Ad Herrennium, Quintilian, and Plato (e.g., see notes on 130–35). Third, Sullivan's front matter presents impressive research on textual authenticity of the Latin text of DDC as well as translation and publication histories for DDC IV and the book as a whole. She fixes the date and occasion of the writing of DDC IV with precision. The sources and parallels from Greco-Roman rhetorical theory are unmatched in the literature. These features alone are worth the cost of The Rhetoric of St. Augustine of Hippo.The remainder of the volume presents a faithful account of a received rhetorical tradition: Augustine's DDC preserves the tradition of rhetoric and philosophy into and through the Middle Ages. Most of the essays correspond with Sullivan's work, featuring DDC IV, which could give the impression that the place to find Augustine's rhetoric is in DDC IV. However, Enos and Thompson et al. do not seem to fall into this trap. Rather, the book suggests that DDC IV is a door to fuller engagement with Augustine. Some indices within the rhetorical tradition do read Augustine and... (shrink)

The case of St. Joseph, the Flying Friar, is one of the most fascinating in the entire history of parapsychology. But until now, there was very little written in English about Joseph. Grosso’s new book fills that void handily, and goes well beyond that by speculating in detail and great subtlety on a variety of surrounding issues, including the efficacy of prayer, the history of religion and religious miracles in general, and the psychology of the period in relation to the (...) development of religious thought. Grosso’s broad range of scholarly competence allows him to weave together these various threads into something much more than a mere recounting of astounding anecdotes about Joseph’s phenomena. Indeed, there’s more in this book than can be covered adequately in a review. So I’ll focus primarily on what I imagine will be news anyway to most JSE readers—namely, the astounding phenomena and the reasons for taking this case seriously. The case of St. Joseph provides the earliest outstanding evidence for human levitation and quite possibly the best from any era. But from a certain conventional viewpoint, the case has several strikes against it from the start. In many people it triggers deep-seated prejudices, about either historical evidence generally or the evidence for alleged religious miracles in particular. Even those willing to be open-minded about nineteenth-century evidence for paranormality may balk at taking seventeenth-century evidence equally seriously. And even those willing to be open-minded about seventeenth-century evidence may draw the line at evidence for religious miracles. Here, they would urge, the problem of biased observation and reporting are especially acute. (shrink)

Ischemic stroke involves numerous and complex pathophysiological mechanisms including blood flow reduction, ionic exchanges, spreading depressions and cell death through necrosis or apoptosis. We used a mathematical model based on these phenomena to study the influences of intensity and duration of ischemia on the final size of the infarcted area. This model relies on a set of ordinary and partial differential equations. After a sensibility study, the model was used to carry out in silico experiments in various ischemic conditions. The (...) simulation results show that the proportion of apoptotic cells increases when the intensity of ischemia decreases, which contributes to the model validation. The simulation results also show that the influence of ischemia duration on the infarct size is more complicated. They suggest that reperfusion is beneficial when performed in the early stroke but may be either inefficacious or even deleterious when performed later after the stroke onset. This aggravation could be explained by the depolarisation waves which might continue to spread ischemic damage and by the speeding up of the apoptotic process leading to cell death. The effect of reperfusion on cell death through these two phenomena needs to be further studied in order to develop new therapeutic strategies for stroke patients. (shrink)

Men often make riskier decisions than women across a wide range of real-life behaviors. Whether this sex difference is accentuated, diminished, or stable under stressful conditions is, however, contested in the scientific literature. A critical blind spot lies amid this contestation: Most studies use standardized, laboratory-based, cognitive measures of decision making rather than complex real-life social simulation tasks to assess risk-related behavior. To address this blind spot, we investigated the effects of acute psychosocial stress on risk decision making in (...) men and women using a standardized cognitive measure and a novel task that simulated a real-life social situation. Participants were exposed to either an acute psychosocial stressor or an equivalent control condition. Stressor-exposed participants were further characterized as high- or low-cortisol responders. Results confirmed that the experimental manipulation was effective. On the IGT, participants characterized as low-cortisol responders made significantly riskier decisions than those characterized as high-cortisol responders. Similarly, in the online chatroom, participants characterized as low-cortisol responders were, relative to those in the Non-Stress group, significantly more likely to make risky decisions. Together, these results suggest that at lower levels of cortisol both men and women tend to make riskier decisions in both economic and social spheres. (shrink)