Highly enantioselective (-)-sparteine-mediated lateral metalation-functionalization of remote silyl protected ortho-ethyl N,N-dialkyl aryl O-carbamates.

We report the enantioselective, lateral deprotonation of ortho-protected or functionalized tertiary N,N-dialkyl aryl O-carbamates 5-7 (Scheme 2 ) and meta-protected carbamates 14, 15, and 20 (Schemes 5 and 7 ) by s-BuLi/(-)-sparteine and subsequent quench with a variety of electrophiles to give products 11-13 and 16, 17, and 21 in yields up to 96% and enantiomeric ratios up to 99:1. The influence of organolithium reagents, ratio of organolithium/(-)-sparteine pair versus N,N-dialkyl aryl O-carbamate starting materials, temperature, solvents, electrophiles, substituents located ortho or meta to the O-carbamate moiety, and O-carbamate N-substituents was investigated. The identical absolute configuration of the stereogenic center of the major enantiomers of the products, as established by single-crystal X-ray analysis for substrates (S)-11c, (S)-19, and (S)-21a, provides evidence for a consistent stereochemical course in the enantioselective deprotonation. Mechanistic investigations, including an estimate of the configurational stability of the benzyllithium species 9 (starting from 12e; Scheme 8 ) and 23 (starting from 17e; Scheme 9 ), both derived by tin-lithium exchange, and 24 (starting from 20; Scheme 9 ) are reported. The experimental results, together with semiempirical molecular orbital calculations (PM3/SMD), are consistent with a process in which enantioinduction occurs in the deprotonation step (Scheme 11 ).

[Palliative care and geriatrics - similarities and opposites]. / Palliative Care und Geriatrie - was ist gemeinsam, was nicht?

Palliative care and geriatrics share many ideas and concepts: both intend to imporve quality of life, both focus on more than the physical domain, and both work in a multiprofessional team. More and more the elderly person attracts notice by palliative care. In multimorbid geriatric patients intentions to cure and to care go alongside sometimes over years in a fragile equilibrium and with uncertain prognosis. Therefore principals of palliative care and geriatrics meet at its best in these patients: improving function plays a major role in any symptom management; how to deal with cognitively impaired patients can be learned from geriatrics; various approaches from curative, palliative and rehabilitative often go hand in hand; decision making is a permanent and sophisticated task in all patients due to prognosis and multimorbidity.

[CME: Self-Determined Dying: The Challenge of Medical End-of-Life Decisions]. / CME: Selbstbestimmung am Lebensende: die Herausforderung medizinischer End-of-Life-Entscheidungen CME-Fragen.

CME: Self-Determined Dying: The Challenge of Medical End-of-Life Decisions Abstract. Modern medical interventions make it possible today to postpone dying. Thus the process of dying confronts with numerous end-of-life decisions. The authority to make such decisions does not lie with the doctors. It is the unique right of the autonomous patient. This right can be experienced as freedom of choice, but also as an excessive demand. Doctors are responsible for supporting their patients in such a way that they become able to make relevant decisions concerning their dying process. In this context modern instruments such as advance directives or advance care planning play an important role. When patients are no longer able to decide for themselves, legal regulations define who is authorised to decide in their place.

[CME/Answers: Self-Determined Dying: The Challenge of Medical End-of-Life Decisions]. / CME/Antworten: Selbstbestimmung am Lebensende: die Herausforderung medizinischer End-of-Life-Entscheidungen.

CME/Answers: Self-Determined Dying: The Challenge of Medical End-of-Life Decisions Abstract. Modern medical interventions make it possible today to postpone dying. Thus the process of dying confronts with numerous end-of-life decisions. The authority to make such decisions does not lie with the doctors. It is the unique right of the autonomous patient. This right can be experienced as freedom of choice, but also as an excessive demand. Doctors are responsible for supporting their patients in such a way that they become able to make relevant decisions concerning their dying process. In this context modern instruments such as advance directives or advance care planning play an important role. When patients are no longer able to decide for themselves, legal regulations define who is authorised to decide in their place.

[Palliative care - difficult decisions at the end of life]. / Palliative Care - schwierige Entscheidungen am Lebensende.

Palliative care comprises the complete treatment and care of patients suffering from incurable, life-threatening or chronically progressive disease. The aim is to provide the patients with the best possible quality of life and support them through the course of their illness until their death, to alleviate their suffering as much as possible and in consideration of the social, spiritual and religious aspects according to the patient's wishes. Palliative care is most important when the dying process and the patient's impending death do seem to be inevitable. Shared decision-making at an early stage of illness is mandatory. Respect for a person's dignity means focusing on their autonomy, their personal preferences and their right to live according to their own values and convictions. A person's autonomy is based on the level of information that he or she is given, the pertinent situation, and the patient's readiness and ability to take responsibility for their own life and end-of-life decisions. Decisions about life-prolonging measures, treatment of pain, dyspnea and palliative sedation require balancing the burden against the benefits. Decision-making must rest with the patient - as far as possible and as long as possible. The potential life-shortening effect of palliative therapy will need to be considered and discussed.

[The Physical Examination of an 'Uncooperative' Elderly Patient]. / Die körperliche Untersuchung des «unkooperativen¼ älteren Patienten.

The Physical Examination of an 'Uncooperative' Elderly Patient Abstract. The physical examination of uncooperative elderly patients regularly presents physicians in the private practice, in the hospital or nursing home with great challenges. The lack of cooperation itself can be an important indication of an underlying medical problem. Important elements to improve the patient's cooperation include ensuring basic needs, sufficient time and patience, adequate communication and good cooperation with relatives and other healthcare professionals. Targeted clinical observation as well as thinking in geriatric syndromes and unmet needs can help to raise physical findings despite limited cooperation. Pathological findings are indicators of impaired organ and functional systems and must be supplemented by a detailed examination.