Positive psychology in health care: defining key stakeholders and their roles.

Lifestyle-related diseases have common risk factors: physical inactivity, poor diet, inadequate sleep, high stress, substance use, and social isolation. Evidence is mounting for the benefits of incorporating effective methods that promote healthy lifestyle habits into routine health care treatments. Research has established that healthy habits foster psychological and physiological health and that emotional well-being is central to achieving total well-being. The Happiness Science and Positive Health Committee of the American College of Lifestyle Medicine aims to raise awareness about strategies for prioritizing emotional well-being. The Committee advocates for collaborative translational research to adapt the positive psychology and behavioral medicine evidence base into methodologies that address emotional well-being in nonmental health care settings. Another aim is to promote health system changes that integrate evidence-based positive-psychology interventions into health maintenance and treatment plans. Also, the Committee seeks to ameliorate health provider burnout through the application of positive psychology methods for providers' personal health. The American College of Lifestyle Medicine and Dell Medical School held an inaugural Summit on Happiness Science in Health Care in May 2018. The Summit participants recommended research, policy, and practice innovations to promote total well-being via lifestyle changes that bolster emotional well-being. These recommendations urge stakeholder collaboration to facilitate translational research for health care settings and to standardize terms, measures, and clinical approaches for implementing positive psychology interventions. Sample aims of joint collaboration include developing evidence-based, practical, low-cost behavioral and emotional assessment and monitoring tools; grants to encourage dissemination of pilot initiatives; medical record dashboards with emotional well-being and related aspects of mental health as vital signs; clinical best practices for health care teams; and automated behavioral programs to extend clinician time. However, a few simple steps for prioritizing emotional well-being can be implemented by stakeholders in the near-term.

Rucaparib maintenance treatment for recurrent ovarian carcinoma after response to platinum therapy (ARIEL3): a randomised, double-blind, placebo-controlled, phase 3 trial.

BACKGROUND: Rucaparib, a poly(ADP-ribose) polymerase inhibitor, has anticancer activity in recurrent ovarian carcinoma harbouring a BRCA mutation or high percentage of genome-wide loss of heterozygosity. In this trial we assessed rucaparib versus placebo after response to second-line or later platinum-based chemotherapy in patients with high-grade, recurrent, platinum-sensitive ovarian carcinoma. METHODS: In this randomised, double-blind, placebo-controlled, phase 3 trial, we recruited patients from 87 hospitals and cancer centres across 11 countries. Eligible patients were aged 18 years or older, had a platinum-sensitive, high-grade serous or endometrioid ovarian, primary peritoneal, or fallopian tube carcinoma, had received at least two previous platinum-based chemotherapy regimens, had achieved complete or partial response to their last platinum-based regimen, had a cancer antigen 125 concentration of less than the upper limit of normal, had a performance status of 0-1, and had adequate organ function. Patients were ineligible if they had symptomatic or untreated central nervous system metastases, had received anticancer therapy 14 days or fewer before starting the study, or had received previous treatment with a poly(ADP-ribose) polymerase inhibitor. We randomly allocated patients 2:1 to receive oral rucaparib 600 mg twice daily or placebo in 28 day cycles using a computer-generated sequence (block size of six, stratified by homologous recombination repair gene mutation status, progression-free interval after the penultimate platinum-based regimen, and best response to the most recent platinum-based regimen). Patients, investigators, site staff, assessors, and the funder were masked to assignments. The primary outcome was investigator-assessed progression-free survival evaluated with use of an ordered step-down procedure for three nested cohorts: patients with BRCA mutations (carcinoma associated with deleterious germline or somatic BRCA mutations), patients with homologous recombination deficiencies (BRCA mutant or BRCA wild-type and high loss of heterozygosity), and the intention-to-treat population, assessed at screening and every 12 weeks thereafter. This trial is registered with ClinicalTrials.gov, number NCT01968213; enrolment is complete. FINDINGS: Between April 7, 2014, and July 19, 2016, we randomly allocated 564 patients: 375 (66%) to rucaparib and 189 (34%) to placebo. Median progression-free survival in patients with a BRCA-mutant carcinoma was 16·6 months (95% CI 13·4-22·9; 130 [35%] patients) in the rucaparib group versus 5·4 months (3·4-6·7; 66 [35%] patients) in the placebo group (hazard ratio 0·23 [95% CI 0·16-0·34]; p<0·0001). In patients with a homologous recombination deficient carcinoma (236 [63%] vs 118 [62%]), it was 13·6 months (10·9-16·2) versus 5·4 months (5·1-5·6; 0·32 [0·24-0·42]; p<0·0001). In the intention-to-treat population, it was 10·8 months (8·3-11·4) versus 5·4 months (5·3-5·5; 0·36 [0·30-0·45]; p<0·0001). Treatment-emergent adverse events of grade 3 or higher in the safety population (372 [99%] patients in the rucaparib group vs 189 [100%] in the placebo group) were reported in 209 (56%) patients in the rucaparib group versus 28 (15%) in the placebo group, the most common of which were anaemia or decreased haemoglobin concentration (70 [19%] vs one [1%]) and increased alanine or aspartate aminotransferase concentration (39 [10%] vs none). INTERPRETATION: Across all primary analysis groups, rucaparib significantly improved progression-free survival in patients with platinum-sensitive ovarian cancer who had achieved a response to platinum-based chemotherapy. ARIEL3 provides further evidence that use of a poly(ADP-ribose) polymerase inhibitor in the maintenance treatment setting versus placebo could be considered a new standard of care for women with platinum-sensitive ovarian cancer following a complete or partial response to second-line or later platinum-based chemotherapy. FUNDING: Clovis Oncology.

Depressive rumination in an analysand after a traumatic treatment.

The author attempts to understand the underpinnings of a ruminative depression that occurred in a patient after a troubled first analysis. Negative therapeutic reaction is often assumed to be the result of a patient's unconscious guilt or masochism and thus an intrapsychic phenomenon, but the author asserts that iatrogenic phenomena in the form of persistent misunderstandings and enactments that remain unanalyzed contribute to a destructive treatment experience. The analysand may relive the failed treatment again and again in his or her mind in an attempt to resolve it. The author asserts that a traumatic treatment experience can foster depressive rumination.

Intermittent annular reduction with Alfieri's repair in the treatment of mitral insufficiency in children: initial results.

OBJECTIVE: Mitral valve insufficiency must be treated by repair whenever as possible as it provides better results - especially within the pediatric population in order to avoid valve replacement inconvenients. The aim of this study is to describe mitral valve repair technique based on an anatomical and functional approach. METHODS: During a 13 months period, eight children (age ranged from 2 and 12 years old 6.37 +/- 3.66) with mitral valve insufficiency underwent intermittent anterior and posterior annuloplasty associated with Alfieri's repair - performed by placing a stitch between the anterior and posterior leaflets in the point of maximal regurgitation thus creating a double orificial mitral valve. RESULTS: There were no surgical deaths. All patients underwent postoperative echocardiography. Three patients showed mild mitral valve insufficiency and five patients showed no insufficiency. The time in intensive care unit ranged from 2 to 4 days (2.5 +/- 0.75), and the time of stay in hospital ranged from 5 to 8 days (6.37 +/- 1.06). CONCLUSION: In spite of the little sample size, the proposed technique proved itself to be simple and effective in the treatment of single mitral valve insufficiency within the pediatric population. In addition, it also yielded satisfactory immediate results. Long-term follow-up is nevertheless necessary in order to evaluate long-term results.

Redução anular intermitente com plastia de Alfieri no tratamento da insuficiência mitral em crianças: resultados iniciais / Intermittent annular reduction with Alfieri's repair in the treatment of mitral insufficiency in children: initial results

OBJETIVO: A insuficiência mitral com indicação cirúrgica na faixa etária pediátrica deve ser tratada por meio de plastia sempre que possível, evitando-se os inconvenientes da substituição valvar. O objetivo deste trabalho é propor técnica de plastia mitral baseada em abordagem funcional e anatômica. MÉTODOS: Durante período de 13 meses, foram operadas oito crianças (idade de 2 a 12 anos, média de 6,37 ± 3,66 anos) portadoras de insuficiência mitral com realização de anuloplastia anterior e posterior de forma intermitente, associadas à plastia de Alfieri (passagem de ponto entre as cúspides no ponto de maior regurgitação, formando valva mitral biorificial). RESULTADOS: Não houve óbito nesta série. Ecocardiografia de controle pós-operatório foi realizada em todos os pacientes, com insuficiência mitral discreta em três pacientes, e sem evidência de insuficiência em cinco pacientes. O tempo de permanência em unidade de terapia intensiva variou de 2 a 4 dias (2,5 ± 0,75), e o tempo de internação hospitalar variou de 5 a 8 dias (6,37 ± 1,06). CONCLUSÃO: Apesar do tamanho limitado da amostra, a opção proposta revelou-se eficaz na avaliação imediata do tratamento da insuficiência mitral isolada em crianças. O acompanhamento dos pacientes faz-se necessário para avaliação dos resultados em longo prazo

OBJECTIVE: Mitral valve insufficiency must be treated by repair whenever as possible as it provides better results - especially within the pediatric population in order to avoid valve replacement inconvenients. The aim of this study is to describe mitral valve repair technique based on an anatomical and functional approach. METHODS: During a 13 months period, eight children (age ranged from 2 and 12 years old 6.37 ± 3.66) with mitral valve insufficiency underwent intermittent anterior and posterior annuloplasty associated with Alfieri's repair - performed by placing a stitch between the anterior and posterior leaflets in the point of maximal regurgitation thus creating a double orificial mitral valve. RESULTS: There were no surgical deaths. All patients underwent postoperative echocardiography. Three patients showed mild mitral valve insufficiency and five patients showed no insufficiency. The time in intensive care unit ranged from 2 to 4 days (2.5 ± 0.75), and the time of stay in hospital ranged from 5 to 8 days (6.37 ± 1.06). CONCLUSION: In spite of the little sample size, the proposed technique proved itself to be simple and effective in the treatment of single mitral valve insufficiency within the pediatric population. In addition, it also yielded satisfactory immediate results. Long-term follow-up is nevertheless necessary in order to evaluate long-term results

What's in a name: what analyst and patient call each other.

Awkward moments often arise between patient and analyst involving the question, "What do we call each other?" The manner in which the dyad address each other contains material central to the patient's inner life. Names, like dreams, deserve a privileged status as providing a royal road into the paradoxical analytic relationship and the unconscious conflicts that feed it. Whether an analyst addresses the patient formally, informally, or not at all, awareness of the issues surrounding names is important.

Silent thoughts, spoken wishes: when candidate experience of the supervisor converges with patient fantasies.

How and why a candidate's private experience of two supervisors emerged in patients' fantasies about them is explored. Four issues are examined in light of two control cases: (1) Patients divide, rather than split, the transference between supervisor and candidate, experiencing both ambivalently. (2) Even a patient with no knowledge of the supervisor's identity may have a fantasy of the supervisor that is congruent with the candidate's experience of the supervisor. (3) When new professional traits emerge in the candidate as he or she identifies with his or her mentor, the patient may attribute them to the invisible person in the room--the supervisor; the patient may intuit and be influenced by the candidate's feelings about the supervisor as well. (4) A patient's fantasies about the supervisor may reflect parallel process in reverse, whereby the patient discerns what is going on between supervisor and candidate through his or her treatment, just as the supervisor reads what is going on between patient and candidate through the candidate's reporting of the treatment. Because the trio is the truth of the training case, it seems fitting and empowering to acknowledge and analyze the role of the supervisor in the patient's mind.