What Use is Freud?

More than a hundred years into our field's development, examining Freud's place in psychoanalytic education is timely. What authority does he hold for psychoanalysts in 2021? Is he still the architect, or overseer, of psychoanalysis? Freud has been a metonym for psychoanalysis, yet the history of Freud's identification with the totality of psychoanalysis has had important unfortunate consequences. Negative aspects of this identification subtly linger, interfering in our collective appreciation of post-Freudian theoretical innovations. Too much of psychoanalysis has been "bought at the company store" of Freud's ideas. Though part of this problem is created by idealizations of Freud, much of it stems from Freud's precocious emphasis on psychoanalytic findings within his tripartite definition of psychoanalysis. As a result, many of his theoretical accounts were taken prematurely as definitive building blocks for a comprehensive psychoanalytic theory, when in fact they were only provisional formulations. Presently, portions of Freud's theories are silently withering on the psychoanalytic vine. Data from the PEP-Web archive reveal the declining use of a set of once important, closely linked conceptions-Freud's psychosexual theory and his characterology-and illustrate the kinds of Freudian ideas that have lost their usefulness. The indispensable and enduring elements in his work are identified.

Quantitative analysis of fetal magnetic resonance phantoms and recommendations for an anthropomorphic motion phantom.

OBJECTIVE: To provide a review and quantitative analysis of the available fetal MR imaging phantoms. MATERIALS AND METHODS: A literature search was conducted across Pubmed, Google Scholar, and Ryerson University Library databases to identify fetal MR imaging phantoms. Phantoms were graded on a semi-quantitative scale in regards to four evaluation categories: (1) anatomical accuracy in size and shape, (2) dielectric conductivity similar to the simulated tissue, (3) relaxation times similar to simulated tissue, and (4) physiological motion similar to fetal gross body, cardiovascular, and breathing motion. This was followed by statistical analysis to identify significant findings. RESULTS: Seventeen fetal phantoms were identified and had an average overall percentage accuracy of 26%, with anatomical accuracy being satisfied the most (56%) and physiological motion the least (7%). Phantoms constructed using 3D printing were significantly more accurate than conventionally constructed phantoms. DISCUSSION: Currently available fetal phantoms lack accuracy and motion simulation. 3D printing may lead to higher accuracy compared with traditional manufacturing. Future research needs to focus on properly simulating both fetal anatomy and physiological motion to produce a phantom that is appropriate for fetal MRI sequence development and optimization.

"Unavoidable Satisfactions": The Analyst's Pleasure.

Analysts have often described their work as depriving, painful, and hard to endure, while its pleasures have been the subject of little commentary. The real history and ongoing temptations of boundary violation long ago made the gratifications of psychoanalytic work a matter of anxiety. Analysts' pleasure in their work was problematized. Some of this problematizing is necessary because of real risk, but much of it is not only unnecessary but misleading and destructive. Psychoanalysts pursue achievement of a unique form of human intimacy, yet acquired habits of professional modesty and humility have encouraged the illusion that analyzing can occur without desire or ambition on the analyst's part. These habits have made it difficult for analysts to openly discuss what they get from the intimacy of analyzing that yields its pleasures. Our field demands that analysts deny that the work provides much more than pain (at least until the conclusion of an analysis), but psychoanalysis both misunderstands and misrepresents itself if we cannot speak of the distinctly broad range of pleasures available in analyzing.

Quenching of dynamic nuclear polarization by spin-orbit coupling in GaAs quantum dots.

The central-spin problem is a widely studied model of quantum decoherence. Dynamic nuclear polarization occurs in central-spin systems when electronic angular momentum is transferred to nuclear spins and is exploited in quantum information processing for coherent spin manipulation. However, the mechanisms limiting this process remain only partially understood. Here we show that spin-orbit coupling can quench dynamic nuclear polarization in a GaAs quantum dot, because spin conservation is violated in the electron-nuclear system, despite weak spin-orbit coupling in GaAs. Using Landau-Zener sweeps to measure static and dynamic properties of the electron spin-flip probability, we observe that the size of the spin-orbit and hyperfine interactions depends on the magnitude and direction of applied magnetic field. We find that dynamic nuclear polarization is quenched when the spin-orbit contribution exceeds the hyperfine, in agreement with a theoretical model. Our results shed light on the surprisingly strong effect of spin-orbit coupling in central-spin systems.

Observation of the fractional quantum Hall effect in graphene.

When electrons are confined in two dimensions and subject to strong magnetic fields, the Coulomb interactions between them can become very strong, leading to the formation of correlated states of matter, such as the fractional quantum Hall liquid. In this strong quantum regime, electrons and magnetic flux quanta bind to form complex composite quasiparticles with fractional electronic charge; these are manifest in transport measurements of the Hall conductivity as rational fractions of the elementary conductance quantum. The experimental discovery of an anomalous integer quantum Hall effect in graphene has enabled the study of a correlated two-dimensional electronic system, in which the interacting electrons behave like massless chiral fermions. However, owing to the prevailing disorder, graphene has so far exhibited only weak signatures of correlated electron phenomena, despite intense experimental and theoretical efforts. Here we report the observation of the fractional quantum Hall effect in ultraclean, suspended graphene. In addition, we show that at low carrier density graphene becomes an insulator with a magnetic-field-tunable energy gap. These newly discovered quantum states offer the opportunity to study correlated Dirac fermions in graphene in the presence of large magnetic fields.

Change in prostate specific antigen following androgen stimulation is an independent predictor of prostate cancer diagnosis.

PURPOSE: We tested the hypothesis that a single exogenous androgen injection in men with low prostate specific antigen would provoke a differential prostate specific antigen response that would correlate with the presence and volume of cancer at biopsy. MATERIALS AND METHODS: Following institutional review board approval 40 men with prostate specific antigen between 2.5 and 4.0 ng/ml were given 1 intramuscular injection of 400 mg testosterone cypionate at the start of the study. Prostate specific antigen and early morning serum testosterone were measured at baseline, 48 hours, and weeks 1, 2 and 4. All men underwent 12-core transrectal ultrasound guided biopsy at week 4. RESULTS: Of the 40 men 18 (45%) were diagnosed with prostate cancer. The mean change in prostate specific antigen from baseline to 4 weeks was 3.1 to 3.4 ng/ml (9.7%) in men found to have benign findings on biopsy compared to a mean increase of 2.9 to 3.8 ng/ml (29%) in those with prostate cancer (p = 0.006). The change in prostate specific antigen following androgen stimulation was significantly associated with the percent of tissue involved with cancer and it was an independent predictor of cancer diagnosis on univariate and multivariate analysis. CONCLUSIONS: An increase in prostate specific antigen following androgen stimulation in men with prostate specific antigen between 2.5 and 4.0 ng/ml was highly predictive of the subsequent diagnosis of prostate cancer and it correlated with disease volume. If these findings are corroborated, prostate specific antigen provocation may become an important strategy to identify men at risk for harboring prostate cancer and minimize the number undergoing unnecessary biopsies.

Access to psychoanalytic ideas in American undergraduate institutions.

To determine the prevalence of teaching about psychoanalytic ideas in the undergraduate curricula of 150 highly ranked colleges and universities, a software-based search was conducted to find references to psychoanalytic content in published course catalogues. Results showed that psychoanalytic ideas were represented somewhere in the curricula of most (though not all) of these schools, and that overall there were many times more courses featuring psychoanalytic ideas outside psychology departments than within them. The data also suggest that there are regional differences in the likelihood an undergraduate will encounter psychoanalytic ideas at these schools. Though psychoanalytic ideas are available in some form in most of these schools' psychology departments, the average number of courses per school is small. At the same time, psychoanalytic ideas have found applications in many areas of the humanities and social sciences. The nature of the presentation of psychoanalytic ideas in these areas, however, may often be unfamiliar to clinically oriented analysts, as seen in examples of the courses that were found. Challenges and opportunities of the current academic climate vis-à-vis organized psychoanalysis are described and various suggestions made regarding how analysts can engage the academic world to its benefit.

Quantifying the impact of prostate volumes, number of biopsy cores and 5alpha-reductase inhibitor therapy on the probability of prostate cancer detection using mathematical modeling.

PURPOSE: Previous studies demonstrated a negative correlation between prostate volume and biopsy yield. By decreasing prostate volume 5alpha-reductase inhibitors may enhance cancer detection, which may explain the greater detection of high grade tumors in the finasteride arm of the Prostate Cancer Prevention Trial. MATERIALS AND METHODS: A mathematical model was constructed to analyze the effects of prostate and tumor volumes, and biopsy core number on cancer detection. The effects of the volume reduction observed with finasteride in the Prostate Cancer Prevention Trial were also modeled, as was the potential reduction in tumor volume needed to explain the observed difference in prostate cancer detection. The model was also applied to the Reduction by Dutasteride of Prostate Cancer Events study. RESULTS: A higher number of biopsies are required to ensure a detection probability of 0.90 or greater in larger glands or with smaller tumors. In the Prostate Cancer Prevention Trial for a tumor volume of 1 cc a 17% increase in the detection rate in the finasteride arm would be predicted if there was no change in tumor volume, likewise the rate would be 11% to 17% for the dutasteride arm of the Reduction by Dutasteride of Prostate Cancer Events study. The calculated reduction in tumor volume needed to explain the difference in cancer detection between the finasteride and placebo arms of the Prostate Cancer Prevention Trial would be 51% to 66%. CONCLUSIONS: This model provides guidance on the optimal number of biopsy cores that accord with an earlier model. These findings also suggest that, if there were no reduction in tumor volume, 5alpha-reductase inhibitor therapy could lead to excess cancer detection, including high grade tumors.

Critical analysis of prostate-specific antigen doubling time calculation methodology.

BACKGROUND: Prostate-specific antigen (PSA) doubling time (PSADT) has emerged as an important surrogate marker of disease progression and survival in men with prostate carcinoma. The literature is replete with different methods for calculating PSADT. The objective of the current study was to identify the method that best described PSA growth over time and predicted disease-specific survival in men with androgen-independent prostate carcinoma. METHODS: PSADT was calculated for 122 patients with androgen-independent prostate carcinoma using 2 commonly used methods: best-line fit (BLF) and first and last observations (FLO). Then, PSADT was calculated by using both a random coefficient linear (RCL) model and a random coefficient quadratic (RCQ) model. Statistical analysis was used to compare the ability of the methods to fit the patients' PSA profiles and to predict disease-specific survival. RESULTS: The RCQ model provided the best fit of the patients' PSA profiles, as determined according to the significance of the added parameters for the RCQ equation (P < or = 0.002). The PSADT estimates from the FLO method, the RCL model, and the RCQ model were highly significant predictors (P < 0.001) of disease-specific survival, whereas estimates from the BLF method were not found to be significant predictors (P = 0.66). PSADT estimates from the RCQ and RCL models provided an improved correlation of disease-specific survival (both R(2) = 0.55) compared to the FLO (R(2) = 0.11) and BFL (R(2) = 0.003) methods. CONCLUSIONS: Random coefficient methods provided a more reliable fit of PSA profiles than other models and were superior to other available models for predicting disease-specific survival in patients with androgen-independent prostate carcinoma. The authors concluded that consideration should be given to applying the RCL or RCQ models in future assessments of PSADT as a predictive parameter.

Pre-treatment nomogram for disease-specific survival of patients with chemotherapy-naive androgen independent prostate cancer.

OBJECTIVE: Our objective was to develop a nomogram that predicts the probability of cancer-specific survival in men with untreated androgen-independent prostate cancer (AIPC). METHODS: AIPC was diagnosed in 129 consecutive patients between 1989 and 2002. No patient received cytotoxic chemotherapy. Univariate and multivariate Cox regression models were used to test the association between prostate-specific antigen (PSA) level at initiation of androgen deprivation, PSA doubling time (PSADT), PSA nadir on androgen deprivation therapy (ADT), time from ADT to AIPC, and AIPC-specific mortality. Multivariate regression coefficients were then used to develop a nomogram predicting AIPC-specific survival at 12-60 mo after AIPC diagnosis. Two-hundred bootstrap resamples were used to internally validate the nomogram. RESULTS: AIPC-specific mortality was recorded in 74 of 129 patients (57.4%). Other-cause mortality was recorded in 7 men (5.4%). Median overall survival was 52.0 mo (mean, 36.0 mo) and median AIPC-specific survival was 54.0 mo (mean, 35.0 mo). In univariate regression models, all variables were significant predictors of AIPC-specific survival (p < or = 0.02). In multivariate models, PSADT and time from androgen deprivation to AIPC remained statistically significant (p < or = 0.004). Bootstrap-corrected predictive accuracy of the nomogram was 80.9% versus 74.9% for our previous model. CONCLUSIONS: A nomogram predicting AIPC-specific survival is between 13% and 14% more accurate than previous nomograms and 6% more accurate than tree regression-based predictions obtained from the same data. Moreover, a nomogram approach combines several advantages, such as user-friendly interface and precise estimation of individual recurrence probability at several time points after AIPC diagnosis, which all patients deserve to know and all treating physicians need to know.

Prognostic model of event-free survival for patients with androgen-independent prostate carcinoma.

BACKGROUND: The current study was conducted to develop a prognostic model of event-free survival (EFS) in men with androgen-independent prostate carcinoma (AIPC). METHODS: Data from 160 patients diagnosed with AIPC between 1989-2002 were reviewed. No patient had received cytotoxic chemotherapy. A univariate Cox proportional hazards model identified significant predictors of EFS. Recursive partitioning analysis divided these significant variables into prognostic risk groups. The final prognostic model was tested with a Cox proportional hazards model. RESULTS: The final prognostic risk model included the presence of metastatic disease at the time of androgen-independent disease progression (P = 0.040), time to prostate-specific antigen (PSA) recurrence (P = 0.043), and PSA doubling time (P < 0.01). Three highly independent risk groups were identified. The observed median EFSs were 6.1 months (95% confidence interval [95= CI], 3.4-8.8 months), 33.6 months (95= CI, 25.3-41.9 months), and 96.1 months (95= CI, 57.9-134.3 months) for the low-risk, intermediate-risk, and high-risk groups, respectively. Each risk group was found to be independently predictive of EFS (P < 0.01). Patients who died of prostate carcinoma experienced significantly more clinical events than those who died of other causes (P < 0.01). CONCLUSIONS: The prognostic model in the current study stratified patients into three highly significant and independent risk groups for EFS. A detailed PSA history and knowledge of metastatic disease are sufficient to risk-stratify patients with AIPC. One very unique aspect of this model was that it was developed from a patient cohort that never received chemotherapy.

Virtual ureteroscopy predicts ureteroscopic proficiency of medical students on a cadaver.

PURPOSE: Training on a virtual reality (VR) simulator has been shown to improve the performance of VR endoscopic tasks by novice endoscopists. However, to our knowledge the translation of VR skills into clinical endoscopic proficiency has not been demonstrated. We established criterion validity for a VR ureteroscopy simulator by evaluating VR trained subjects in a cadaver model. MATERIALS AND METHODS: A total of 32 participants, including 16 medical students and 16 urology residents, were evaluated at baseline on a VR ureteroscopy simulator (Uromentor, Simbionix, Lod, Israel), performing simple diagnostic ureteroscopy. The students then underwent 5 hours of supervised training on the simulator. Two weeks later all participants were reevaluated (VR2) on the simulator when repeating the initial task. Each participant was then assessed on the performance of a similar diagnostic ureteroscopy in a male cadaver. RESULTS: In medical students VR2 and cadaver performances correlated closely for several measured parameters (total time for task completion and overall global ratings score). In contrast, there was little correlation between the 2 performances in residents. Indeed, performance on the cadaver correlated more closely with the training level than VR2 scores. Despite VR training medical students were unable to perform cadaver ureteroscopy comparably to residents. CONCLUSIONS: For novice endoscopists performance on the simulator after training predicted operative (cadaver) performance and, thus, it may be useful for the education and assessment of physicians in training. However, VR training is unable to override the impact of clinical training, although it may help shorten the learning curve early in training.

The natural history of androgen independent prostate cancer.

PURPOSE: We describe the natural history of androgen independent prostate cancer (AIPC) in the modern prostate specific antigen (PSA) era. MATERIALS AND METHODS: Data from 160 patients diagnosed with AIPC between 1989 and 2002 were reviewed. No patient had received cytotoxic chemotherapy. Univariate and multivariate proportional hazards models were constructed to identify significant risk factors for cancer specific survival. Recursive partitioning analysis stratified patients into prognostic risk groupings. The types and frequencies of cancer specific complications per risk grouping were compared. RESULTS: The final prognostic risk model included nadir PSA on androgen deprivation therapy (p = 0.023), time to PSA recurrence (p = 0.006) and prostate specific antigen doubling time (p <0.01). Three highly independent risk groupings were identified. The observed median cancer specific survivals were 14.0 months (95% CI, 8.3-19.8), 38.4 months (95% CI, 26.9-49.9) and 89.1 months (95% CI, 69.0-109.2) for low, intermediate and high risk groupings, respectively (p <0.001). Patients in the low risk grouping experienced significantly fewer cancer specific complications (p = 0.003). CONCLUSIONS: This prognostic model stratified patients into 3 highly significant and independent risk groupings. A detailed PSA history alone is sufficient to risk stratify patients with AIPC.

Prostate-specific antigen doubling time predicts response to deferred antiandrogen therapy in men with androgen-independent prostate cancer.

OBJECTIVES: To identify the pretreatment variables that are predictive of response and the duration of response to deferred antiandrogen therapy in men with androgen-independent prostate cancer (AIPC). METHODS: A total of 375 patients receiving androgen deprivation therapy for advanced prostate cancer between 1977 and 2002 had medical records available for retrospective review. Of these 375 patients, 163 were diagnosed with AIPC. The inclusion criteria included (1) diagnosis of AIPC and (2) treatment with deferred antiandrogen therapy. AIPC was biochemically defined as two consecutive rises in the prostate-specific antigen (PSA) level during androgen deprivation therapy. The treatment response to deferred antiandrogen therapy was defined as a 50% or greater decline in the pretreatment PSA level. The prognostic value of various pretreatment parameters was determined with the appropriate statistical methods and tested with a Cox proportional hazards model. RESULTS: Of the 163 patients with AIPC, 36 were treated with deferred antiandrogen therapy. Of these 36 patients, 12 (33.3%) experienced a PSA response. The median PSA failure-free survival was 9.0 months (95% confidence interval 5.2 to 12.9). The only pretreatment variable predictive of a PSA response was the PSA doubling time (PSADT). The mean PSADT in responders was 12.7 months versus 7.5 months in nonresponders (P = 0.037). Moreover, PSADT was the only statistically significant variable on univariate analysis of PSA failure-free survival in responders (hazard ratio 0.202, 95% confidence interval 0.041 to 0.990, P = 0.049). No statistically significant difference was found in cancer-specific survival between responders and nonresponders (P = 0.1501). CONCLUSIONS: The PSADT predicted both the response and the duration of the response to deferred antiandrogen therapy in patients diagnosed with AIPC.