Dear Ladies and Gentlemen

2. Dear Ladies and Gentlemen

3. "…the earth was unformed and void …and God saw everything that He had made and behold, it was very good". (Genesis I; 2, 31) • Happiness (eudaimonia) is the meaning and the purpose of life, the whole aim and end of human existence (Aristotle). • "But man is born unto trouble"( Job 5, 7).

4. I am happy to have arrived from the Holy Land to Edinburgh, the capital of Scotland. It is an honour to present you with my new entropy definition of human happiness and suffering and the new clinical and pathological entity in medicine – Aminoff Suffering Syndrome. • The term entropy was coined in 1862 byRudolfClausius based on the Greekwordεντροπία [entropía], a turning toward, from εν- [en-] (in) and τροπή [tropē] (turn, conversion). • The argument that life feeds on negative entropy or negentropy is asserted in the book " What is life" by physicistErwinSchrodinger.(1944) Schrodinger is also notable for having won the 1933 Nobel Prize for his development of the Schrodinger equation. On this basis, he situates the following definition: - (entropy) = k log (1/D), where k is the Boltzmann constant, 1/D, can be regarded as a direct measure of order. Negative entropy, or negentropy may be defined also asanti- entropy which is usually used in our presentation.

5. Entropy may be defined as a measure of chaos, or a measure of lack of order. If the system is perfected, managed correctly or any other description that can define the state of that order, then the entropy of the system is lowered accordingly, and is thus defined as a process of the depression of entropy, negative entropy or anti-entropy. The Almighty created man to for contentment, and not for suffering. The creation of the universe was a leap from absolute entropy to substance and the vital world. The goal of creating the universe and humans was to create enjoyment and pleasure by depressing the level of entropy.Unfortunately, in reality, human suffering, life and disease are inseparable. Is this suffering absolutely necessary? Suffering was omnipresent even prior to the creation of humans. From the moment the Almighty created the vital world, suffering has been inherent in its concept.

6. Some forms of human suffering are well known: Suffering of: a pregnant woman, and childbirth; a baby; a child; an adolescent; an adult and an elderly person; Suffering of a soldier; a prisoner; the poor; the rich; of the wise; the stupid; of love; from struggle for survival ; struggle among human beings; wars between nations; illness; ageing; and dying. After so much suffering in life, perhaps there is also immense suffering after death, in Hell. So what, therefore, is the purpose of birth? How can all this suffering be avoided? Human enjoyment and suffering has received limited attention in philosophy, psychology, sociology and medical education, research, and practice (Cassell, 1982; Aminoff 1999- 2015, Lesho, 2003). Definition of the suffering and enjoyment of healthy and sick individuals and estimation of human happiness and suffering by objective tools is of profound importance in human beings and daily medical practice (Aminoff, et al. 2004).

7. We developed and proposed the entropy theory as a new definition of human suffering and torment, and human pleasure, satisfaction and happiness. Our hypothesis is that suffering and satisfaction are functions of the level of human entropy (Aminoff 2001, 2009, 2010, 2011). Enjoyment and suffering are traits that only pertain to the animate world. It is not known whether bacteria suffer and enjoy, but plants surely do, and there is no doubt that animals also sense pleasure and suffering. A world that is inanimate does not suffer or enjoy. All remote events that at times are difficult to comprehend, such as the forces of nature, i.e., clashing of forces or whatever occurs in the universe at large, may ensue without pleasure or suffering. Fundamentally, our lives comprise constant struggle for more: progress, the need to acquire and receive, increased sophistication, and acquisition of power, beauty and wealth.

8. What then are pleasure and suffering? Firstly, these are positive and negative sensations. Humans possess five conscious senses, i.e. hearing, sight, smell, taste and touch. An odor may be either bad or good, food is either tasty or bland, a touch may be pleasant, such as the feel of a baby's silky skin, or an agonizing touch of burning metal. The sight of flowers blossoming in a field induces joy, and devastation is felt at the destruction of war. We enjoy listening to good music and suffer when sound is at full volume. Positive perceptions also instigate pleasure, and negative perceptions cause misery, particularly the perception of pain. Positive emotions, such as the seven blessings mentioned at a wedding, i.e. joy and gladness, groom and bride, mirth and song, delight, love, brotherhood, peace and companionship, all produce pleasure, satisfaction and happiness. Negative emotions, such as fear, anxiety, tension, anger, frustration, concern, helplessness and depression are all sources of suffering. In cognitive life thoughts may be either pleasurable, or distressing, and are sources of enjoyment, or suffering, respectively.

9. My definition of human suffering is that: "Human suffering is the complexity of negative sensations, perceptions, emotions, or human thoughts that arise due to a process, or condition of an increasing level of entropy of a person’s organism, empathy for others, or germane surroundings in the past, present, or of a threat in the future". Human satisfaction may be defined as the complexity of positive sensations, perceptions, emotions, or thoughts of a person that arise due to the process, or state of depressive level of entropy of the individual’s organism, empathy for others, or germane surroundings in the past, present or that which will take place in the future.

10. I am presently only mentioning the suffering of the elderly, i.e. those who have no verbal communication with their surroundings, and who suffer from severe end-stage brain diseases such as Alzheimer’s disease and other dementias. Our recently developed Mini Suffering State Examination (MSSE) scale is the first objective clinical tool for evaluation of suffering level in end stage dementia (Aminoff, 1999). The results of clinical experience with this scale were presented at world and regional congresses in Berlin (1999), Jerusalem (2000), Vancouver (2001), Stockholm (2002), Tokyo (2003), Las Vegas (2004), Rio-de-Janeiro (2005), Madrid (2006), Saint-Petersburg (2007), Trondheim (2008), Paris (2009), Honolulu (2010), Athens (2011), Copenhagen (2012),Seoul (2013), St. Anton am Arlberg (2014)  and Israeli Parliament (2005) and now in Edinburgh.

12. The MSSE scale is available in English, Hebrew, Dutch and Spanish, and covers 10 items (range 0-10) (Table 1). Based on clinical experience, the following items were included in the MSSE: Not calm, screams, pain, decubitus ulcers, malnutrition, eating disorders, invasive action, unstable medical condition, suffering according to medical opinion, and suffering according to family opinion. A high MSSE scale score with range 7-10 indicates a high level of suffering and reflects the severity of the medical condition in end-stage dementia. The MSSE scale was tested using the Cronbach model, which demonstrated its significant reliability ( = 0.798). Validity of the MSSE scale was proven by Pearson correlation with Symptom Management in End-of-Life in Dementia (SM–EOLD) scale (r = 0.574, P < 0.0001), and Comfort Assessment in Dying with Dementia (CAD–EOLD) scale (Volicer, Hurley and Blasi, 2001) (r = -0.796, P < 0.0001).

14. The group differences among the survival times of the three MSSE scale scores was evaluated by Kaplan-Meier analysis (Log Rank, P=0.0018, Breslow, P=0.0027) and were significant. The results of the Cox proportional Hazard model of survival showed a high correlation between high MSSE scale score and high risk of mortality and short survival of end-stage dementia patients during the last 6 months of life (P = 0.013) (Aminoff and Adunsky, 2006). According to the MSSE scale, it has been confirmed that end-stage dementia patients represent a heterogeneous group and have different levels of suffering. The results of our research showed that care in the geriatric department fails to decrease the high level of suffering of end-stage dementia patients. The total score of MSSE scale on the day of admission was 5.62  2.31, and increased to 6.89  1.95 on the last day of life with a significant difference (P < 0.0001) (Aminoff and Adunsky, 2004). Despite traditional medical and nursing care, a large proportion of dying dementia patients diagnosed with Aminoff Suffering Syndrome experience increased suffering as they approach death (Aminoff 2006-2015).

15. Aminoff Suffering Syndrome a New Clinical and Pathological Entity in medicine. First presentationofAminoffSufferingSyndromeby us was in 10th International Conference on Alzheimer's Disease and Related Disorders; July 15 - 20, 2006, Madrid. Alzheimer’s Disease: New Advances, Medimond International Proceedings; 2007:55 – 59. Aminoff Suffering Syndrome Characterized by: A high MSSE scale score; Less than 6 months survival (for terminal patients) and than 1 month survival (for actively dying patients); Irreversible and intractable aggravation of medical condition and suffering until demise.

16. Results of study generalized in recently published book: AminoffBechorZvi, MD, PhD Measurement of Suffering in End-Stage Alzheimer’s Disease Probook, Dyonon, Tel- Aviv, 2007 And Articles published in Scientific Professional Journals.

17. Aminoff Suffering syndromemay be the key criterion: For enrollingend-of-life dementia patients for palliative and hospice treatment; For the development of new alternative setting approaches, such as: Relief of Suffering Units

18. What can be done to make the life of a baby, a child, an adult, and an older person more pleasurable? These are questions we hope will be resolved in the future.

19. Thanks for attention