Improving psychological therapies for psychosis: exploring the utility and benefit of using metacognitive training within standard psychological care - a case series

Cognitive Behavioural Therapy for Psychosis (CBTp) is currently recommended by National Guidelines (NICE) as an adjunct to antipsychotic medication. However, access to CBTp remains generally poor. Moreover, its effectiveness on positive symptoms and other outcomes including stigma remains modest, highlighting the importance of continuously improving “gold standard” therapies for psychosis further. For this project, first a meta-analysis on the correlates of personal stigma in psychosis was conducted. Stigma was associated with a range of symptoms including positive symptoms, depression, hopelessness and suicidality. Moreover, stigma was inversely related to a range of well-being outcomes including recovery, self-esteem and quality of life; highlighting the importance of routinely offered psychotherapeutic interventions to not only target symptoms, but to also address feelings of stigmatisation. One recently developed intervention, with a focus on the cognitive infrastructure implicated in the formation and maintenance of delusions, whilst also targeting issues of stigma and self-esteem is Metacognitive Training (MCT). Whereas studies are still emerging, individualised MCT (MCT+) appears particularly effective in targeting delusional symptoms, with studies showing both short and long term effects. The second, and empirical part of the project was therefore to evaluate the benefit of utilising MCT+ within standard treatment across NHS Lothian, Scotland, in order to evaluate whether MCT can be used to improve psychological therapies for psychosis further. To do this, a quasi-randomised case series was conducted, where individuals currently receiving non-structured psychological support or were on the waitlist to receive CBTp, were invited to take part, and allocated to receive up to 20 sessions of standard CBTp or MCT+. Study one sought to evaluate whether MCT+ would lead to additional improvements in delusions compared to CBTp, and to explore potentially differential mechanisms of action between the two treatment modalities. Data on delusions and self-reported cognitive biases were collected weekly during a four week baseline period, on a session-by-session basis throughout therapy, weekly for four weeks after therapy as well as at a follow up session 12 weeks after therapy. Graphical representations of change before, during and after therapy and multilevel modelling (MLM) was used to analyse data. Out of 19 individuals allocated to treatment 16 participants completed 4 or more sessions of CBTp or MCT+ and were included in the analysis. Results indicated comparable reductions in delusions and the jumping to conclusions bias across both treatment modalities. However, individuals receiving MCT+ also showed reductions in self-reported belief inflexibility as well as the external attribution bias, the latter of which predicted delusion reduction across sessions. Both treatment modalities were also associated with improved functioning and reduced general psychopathology, whereas no significant change in self-stigma was seen. Study two sought to build on Study one, and utilised thematic analysis to evaluate qualitative feedback given by patients on their experience of therapy, as well as interviewing clinicians about the experience of using MCT+ within standard care. Feedback from both patients and clinicians indicated that MCT+ may be a useful resource that can be feasibly implemented and effectively utilised in order to maximise access and choice to psychological treatments for psychosis. Moreover, reflecting the findings of study one, both patients and clinicians found the material on attribution particularly useful. Based on the outcomes of this project, it was concluded that whilst MCT+ did not enhance delusions reduction above standard CBTp, it may be an effective complement to standard therapy for delusions through its focus on cognitive biases, where MCT elements focussing on attribution appeared to be particularly useful. Due to its modular structure and ease of administration, the finding that MCT+ performed similarly to standard CBTp is encouraging. To build on the current project, future studies should therefore evaluate the feasibility and utility of implementing MCT within practices where psychotherapy is not routinely offered such as in psychiatric nursing settings. This is particularly important in order to increase access to effective psychological support for individuals with psychosis, who may otherwise not have access to CBTp

Organiskt kol i svenskt markvatten : förändras det och varför?

Since the 1980s, many lakes and rivers have become browner in color. This phenomenon is called browning and is due to an increase in organic carbon, or humus, in the water. The main reason for this is thought to be a recovery from the acidification that occurred in the latter part of the 20th century. In the following report, the aim was to investigate whether the concentration of organic carbon has changed over a long period of time and the reasons for this. Soil water data over a 30-year period (1986 - 2023) were obtained from Krondroppsnätet with sample plots scattered throughout Sweden, as well as three sites from the Integrated Monitoring (IM) programme. Since the organic carbon in surface water comes from the soil, it is important to study the factors controlling its solubility there. Measured and calculated variables from the data sources focused on in the results were pH, sulphate concentration, total organic carbon (TOC) concentration, alkalinity, net charge of soil water ions and charge density (net charge/TOC) of humus molecules. In the results, time series showed that pH increased and sulphate ion concentration decreased throughout the period, which is due to the recovery from acidification. Time series for TOC show that the concentration is high before 2000, then it is lower between 2000 - 2010 before increasing again after 2010. Correlation plots of the variables were divided into soil types due to different TOC and pH contents. The correlation plots for TOC and pH and net charge and pH both showed a negative correlation for the podzols while the histosols had a positive correlation. A clear positive correlation was found between net charge and TOC. The charge density seemed to increase with increasing pH, especially for the IM areas. For Krondroppsnätet, there was a positive correlation between net charge and sulphate content. The fact that the TOC time series did not show a constant increase was surprising given the browning observed in several other studies. It was also surprising that TOC concentrations decreased with increasing pH for podzols in particular, since recovery from acidification contributes to increased pH and would, according to that theory, contribute to increased TOC concentrations. What distinguishes this report from others is that the data analysed is from a long period of time, which gives a better overall picture of the changes than if it had been a shorter period.Sedan 1980-talet har många sjöar och vattendrag fått en brunare färg. Fenomenet kallas för brunifiering och beror på att halten organiskt kol, eller humus, ökar i vattnet. Den främsta orsaken till detta tror man beror på att det sker en återhämtning från den försurning som rådde under den senare delen av 1900-talet. I följande rapport var syftet att undersöka om det organiska kolets koncentration har ändrats över en lång tid och orsakerna till det. Markvattendata över en 30-årsperiod (1986 – 2023) erhölls från Krondroppsnätet med provytor utspridda över hela Sverige, samt tre områden från miljöövervakningsprogrammet IM (Integrated Monitoring). Eftersom det organiska kolet i ytvatten kommer från marken är det viktigt att studera faktorerna som kontrollerar dess löslighet där. Uppmätta och beräknade variabler från datakällorna som fokuserades på i resultatet var pH, sulfatkoncentration, TOC-koncentration (total organic carbon), alkalinitet, nettoladdning hos markvattnets joner och laddningsdensitet (nettoladdning/TOC) hos humusmolekylerna. I resultatet visade tidsserier att pH ökat och koncentrationen av sulfatjoner minskat under hela perioden som beror på återhämtningen från försurningen. Tidsserier för TOC visar att koncentrationen är hög innan år 2000, därefter är den lägre mellan 2000 - 2010 innan den ökar igen efter 2010. Sambandsdiagram på variablerna delades upp i jordmåner på grund av olika halt TOC och pH. Sambandsdiagrammen för TOC och pH samt nettoladdning och pH visade båda ett negativt samband för podsolerna medan histosolerna hade ett positivt samband. Ett tydligt positivt samband visade sig mellan nettoladdning och TOC. Laddningsdensiteten verkade speciellt för IM-områdena öka med ökat pH. För Krondroppsnätet fanns det ett positivt samband mellan nettoladdning och sulfathalt. Att TOC-tidsserierna inte visade konstant ökning var förvånande med tanke på den brunifiering som flera andra studier sett. Det var även förvånande att TOC-koncentrationerna minskade med ökat pH för framför allt podsoler eftersom återhämtningen från försurningen bidrar till ökat pH och skulle enligt den teorin bidra till ökad koncentration TOC. Det som särskiljer denna rapport från andra är att den analyserade datan är från en lång tidsperiod som ger en bättre helhetsbild av förändringarna än om det varit en kortare period

Norrlands Hawaii

Utanför den norrländska staden Sundsvall ligger Alnö, som på sin södra del berikats med många vackra badstränder. Ön är mycket populär sommartid, då många byter ut lägenheterna i staden mot sommarstugan på Alnö. Man brukar säga att öns befolkning mer än dubbleras under sommartid och kanske är det därför ön ofta kallas ”Norrlands Hawaii”. En av de mest populära stränderna på ön är Tranviken, en stor öppen strand där det anlagts bland annat restaurang, badbassänger och camping. Tranvikens har fina, funktionella byggnader och bassänger, men områdets gröna ytor har i dagsläget en del brister. Rabatter står tomma, växter är döda och vresrosor växter in i gångar, gräsmattor och andra ställen den inte bör växa på. Min gestaltning bygger på en grundlig analys och ett tydligt koncept, med bakgrund i platsanalys och kundmöte med Tranvikens förvaltare Lillemor Larsson, där jag kunde ta del av önskemål och förväntningar. Larsson vill att Tranviken ska spela på öns smeknamn och ge en tropisk exotisk känsla till platsen. Eftersom ståndorten är mycket speciellt på en sandstrand fick vi kompromissa och beslutade därför att det exotiska temat fick koncentrera sig till Tranvikens huvudentré med tillhörande bangolf, här fylls planteringarna av härdiga trädgårdsväxter med exotiska intryck, mixade med utplanteringsväxter och sommarblommor med typiska exotiska karaktärsdrag. I Tranvikens övriga områden har jag i min gestaltning skapat ett mer ståndortsanpassat tema där jag sammanfört typiskt norrlänska växter och material med växter från Medelhavet. Med fokus på umgänge, familj och gemenskap är Tranviken en plats där människor i alla åldrar kan mötas, leka och umgås

Renal transplantation in patients with HIV/AIDS

The human immunodeficiency virus (HIV)-infected patient is more prone to developing both acute and chronic renal failure than the general population. Renal disease specific to the HIV-infected population include HIV-associated nephropathy (HIVAN), mostly prevalent in the black population, and HIV immune complex kidney disease (HIVICK), which is more common in the white population. Some immune complex diseases of the kidney are thought, in the majority of cases, to originate from a co-infection with hepatitis C virus (HCV). As the life expectancy of this population is getting longer they are more likely to suffer from end organ damage due to age related diseases such as hypertension (HTN) and diabetes mellitus (DM). The kidney function can be monitored by estimated glomerular filtration rate (eGFR), albumin/creatinine ratio (ACR) and protein/creatinine ratio (PCR). Using ACR and PCR enables estimation of the renal function even in dilute urine and does not need sensitive lab machines, necessary for detecting tubular proteins in urine, that are not available at many hospitals. Treatment of established kidney disease is by managing modifiable factors, such as HTN, body weight and drug regimen as far as possible. Renal replacement therapy is indicated as for other patient groups with decreased renal function. If the patient fulfil certain criteria they are eligible for a renal transplant. Social stigma and lack of knowledge has led fewer HIV-infected patients to want transplantation. Among the HIV-specific criteria for transplantation include that the patient has to be well regulated with combined ART (cART) for at least six months and without a history of opportunistic infections. Immunosuppressive (IS) therapy was for a long time thought to enable the virus to freely replicate and hasten the progression to AIDS and death. Studies have later shown that by suppressing the immune system one is preventing activation of CD4+ T cells and, because the HIV-virus infect activated cells, they also protect new T-cells from being infected. IS may thus, on the contrary, even be beneficial in these patients. The drug interactions between IS and ART are many and complex and it is beneficial with multidisciplinary teams, including a infectologist and nephrologist, to choose the optimal therapy. Blood levels of the drugs should be checked with regular intervals to ensure therapeutic levels and prevent nephrotoxicity or rejection. The outcome after transplantation is continuing to improve. The frequency of rejection episodes is higher in this population, but the graft and patient survival is similar to the general population. Meta-analyses have concluded that renal transplantation should be offered to patients who fulfill the criteria, although the strength of evidence is very low due to small study samples

Renal transplantation in patients with HIV/AIDS

The human immunodeficiency virus (HIV)-infected patient is more prone to developing both acute and chronic renal failure than the general population. Renal disease specific to the HIV-infected population include HIV-associated nephropathy (HIVAN), mostly prevalent in the black population, and HIV immune complex kidney disease (HIVICK), which is more common in the white population. Some immune complex diseases of the kidney are thought, in the majority of cases, to originate from a co-infection with hepatitis C virus (HCV). As the life expectancy of this population is getting longer they are more likely to suffer from end organ damage due to age related diseases such as hypertension (HTN) and diabetes mellitus (DM). The kidney function can be monitored by estimated glomerular filtration rate (eGFR), albumin/creatinine ratio (ACR) and protein/creatinine ratio (PCR). Using ACR and PCR enables estimation of the renal function even in dilute urine and does not need sensitive lab machines, necessary for detecting tubular proteins in urine, that are not available at many hospitals. Treatment of established kidney disease is by managing modifiable factors, such as HTN, body weight and drug regimen as far as possible. Renal replacement therapy is indicated as for other patient groups with decreased renal function. If the patient fulfil certain criteria they are eligible for a renal transplant. Social stigma and lack of knowledge has led fewer HIV-infected patients to want transplantation. Among the HIV-specific criteria for transplantation include that the patient has to be well regulated with combined ART (cART) for at least six months and without a history of opportunistic infections. Immunosuppressive (IS) therapy was for a long time thought to enable the virus to freely replicate and hasten the progression to AIDS and death. Studies have later shown that by suppressing the immune system one is preventing activation of CD4+ T cells and, because the HIV-virus infect activated cells, they also protect new T-cells from being infected. IS may thus, on the contrary, even be beneficial in these patients. The drug interactions between IS and ART are many and complex and it is beneficial with multidisciplinary teams, including a infectologist and nephrologist, to choose the optimal therapy. Blood levels of the drugs should be checked with regular intervals to ensure therapeutic levels and prevent nephrotoxicity or rejection. The outcome after transplantation is continuing to improve. The frequency of rejection episodes is higher in this population, but the graft and patient survival is similar to the general population. Meta-analyses have concluded that renal transplantation should be offered to patients who fulfill the criteria, although the strength of evidence is very low due to small study samples

Renal transplantation in patients with HIV/AIDS

The human immunodeficiency virus (HIV)-infected patient is more prone to developing both acute and chronic renal failure than the general population. Renal disease specific to the HIV-infected population include HIV-associated nephropathy (HIVAN), mostly prevalent in the black population, and HIV immune complex kidney disease (HIVICK), which is more common in the white population. Some immune complex diseases of the kidney are thought, in the majority of cases, to originate from a co-infection with hepatitis C virus (HCV). As the life expectancy of this population is getting longer they are more likely to suffer from end organ damage due to age related diseases such as hypertension (HTN) and diabetes mellitus (DM). The kidney function can be monitored by estimated glomerular filtration rate (eGFR), albumin/creatinine ratio (ACR) and protein/creatinine ratio (PCR). Using ACR and PCR enables estimation of the renal function even in dilute urine and does not need sensitive lab machines, necessary for detecting tubular proteins in urine, that are not available at many hospitals. Treatment of established kidney disease is by managing modifiable factors, such as HTN, body weight and drug regimen as far as possible. Renal replacement therapy is indicated as for other patient groups with decreased renal function. If the patient fulfil certain criteria they are eligible for a renal transplant. Social stigma and lack of knowledge has led fewer HIV-infected patients to want transplantation. Among the HIV-specific criteria for transplantation include that the patient has to be well regulated with combined ART (cART) for at least six months and without a history of opportunistic infections. Immunosuppressive (IS) therapy was for a long time thought to enable the virus to freely replicate and hasten the progression to AIDS and death. Studies have later shown that by suppressing the immune system one is preventing activation of CD4+ T cells and, because the HIV-virus infect activated cells, they also protect new T-cells from being infected. IS may thus, on the contrary, even be beneficial in these patients. The drug interactions between IS and ART are many and complex and it is beneficial with multidisciplinary teams, including a infectologist and nephrologist, to choose the optimal therapy. Blood levels of the drugs should be checked with regular intervals to ensure therapeutic levels and prevent nephrotoxicity or rejection. The outcome after transplantation is continuing to improve. The frequency of rejection episodes is higher in this population, but the graft and patient survival is similar to the general population. Meta-analyses have concluded that renal transplantation should be offered to patients who fulfill the criteria, although the strength of evidence is very low due to small study samples

ISHOD TRANSPLANTACIJE BUBREGA KOD BOLESNIKA S LUPUSNIM NEFRITISOM – ISKUSTVO JEDNOG CENTRA I PREGLED LITERATURE

Aims: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease in patients with systemic lupus erythematosus (SLE). Still, these patients tend to fare worse than other patient groups with chronic kidney failure. The main aim of this retrospective observational study was to evaluate the outcomes of KT in patients with SLE. Methods: Data were obtained from medical records and charts. Results: From February 2007, a total of 12 SLE patients, average age 37 (18-56) years, underwent deceased donor KT at our Center. Comorbidities were primarily cardiovascular. At the time of KT, 91.7% of patients showed no signs of SLE activity. Immunological matching was favorable and all allografts showed satisfactory initial function. Median graft survival for the whole patient population was 41 (0-93) months. In 66.7% of patients with stable graft function, median survival was 61 (22-93) months, in three patients longer than fi ve years. One patient died 4 months after the transplantation from neurologic complications, whereas 25% of allografts were lost in the early post-transplant period, in 0-5 months after KT. Our patient outcomes showed no clear correlation between age, previous KT or number of comorbidities. Episodes of acute rejection or recurrent lupus nephritis brought a higher risk of poor outcome. Conclusion: While there still are many unanswered questions relating to the management of this immunologically very sensitive group of patients, forming a multidisciplinary transplantation team would enable pre-transplant evaluation of SLE patients with possible risk assessment and adjustment of follow up strategy to achieve an optimal survival outcome.Uvod i ciljevi: Transplantacija bubrega metoda je izbora u liječenju završnog stadija kronične bubrežne bolesti u bolesnika s lupusnim glomerulonefritisom (LN). Ipak, u usporedbi s drugim bolesnicima ova skupina unatoč napretku u liječenju i dalje pokazuje lošiji ishod. Glavni cilj ovog istraživanja bio je usporediti ishode našeg Centra s ishodima drugih studija te raspraviti nove mogućnosti u praćenju i liječenju ove skupine pacijenata. Ispitanici i metode: Svi istraživani parametri prikupljeni su iz dostupne medicinske dokumentacije. Rezultati: 12 bolesnika sa SLE, prosječne dobi 37 (18-56) godina, učinjena je transplantacija u našem Centru od veljače 2007. godine. Svi su bolesnici bili primatelji presatka kadaveričnog darivatelja. Najčešći komorbiditeti bile su kardiovaskularne bolesti. U vrijeme transplantacije 91,7% bolesnika bilo je u potpunoj serološkoj i kliničkoj remisiji osnovne bolesti. Stupanj tkivne podudarnosti bio je zadovoljavajući, a uspostavljanje bubrežne funkcije promptno u svih ispitanika. Prosječno vrijeme preživljenja presatka iznosilo je 41 (0-93) mjesec. Kod 66,7% bolesnika sa stabilnom bubrežnom funkcijom, to je vrijeme iznosilo 61 (22-93) mjesec, za tri je presatka zabilježeno preživljenje dulje od 5 godina. Tri su bolesnika graftektomirana (25%), dok je u jedne olesnice zabilježen smrtni ishod. Gubitak presadaka nastupio je u ranom posttransplantacijskom razdoblju – od 0 do 5 mjeseci nakon transplantacije. Zaključak: Iako postoje brojna neistražena i neodgovorena pitanja vezana uz zbrinjavanje ove imunološki vrlo osjetljive i zahtjevne skupine bolesnika, pažljiva skrb prije i nakon transplantacije te uska suradnja nefrologa i imunologa omogućavaju dobar ishod uz značajno povećanje kvalitete života

Efficacy of Mentalization-Based Group Therapy for adolescents:A pilot randomised controlled trail

oai:ojs.pkp.sfu.ca:article/2647Background: Suicide is the leading cause of death in adolescents. Furthermore, up to one quarter of adolescents who self-harm will repeat self-harm within one year, highlighting the need for evidence-based prevention and treatment services. Mentalization Based Therapy (MBT) has yielded promising outcomes for individuals who self-harm, however to date only one study has examined MBT in adolescents, wherein the treatment protocol consisted of individual and family therapy. Currently, there has been no development or examination of MBT-A in a group format for adolescents. Methods/Design: The present study is a randomised controlled single blind feasibility trial that aims to (1) adapt the original explicit MBT introductory group manual for an adolescent population (MBT-Ai) and to (2) assess the feasibility of MBT-Ai through examination of consent rates, attendance, attrition and self-harm. Participants are adolescents presenting to Child and Adolescent Mental Health Services (CAMHS) with self-harming behaviors within the last 6 months. Young people will be randomised to a 12-week MBT-Ai group plus treatment as usual (TAU) or TAU alone. Participants will be assessed at baseline and at 12-, 24- and 36-weeks post-baseline. Discussion: This paper describes the development of a treatment manual and the protocol of a randomised controlled feasibility trial of MBT-Ai aimed at treating adolescents who self-harm. Further investigation of a full-scale trial will be necessary to instill benefits if pilot results suggest efficacy. Trial registration: NCT0277169

RENAL TRANSPLANTATION IN PATIENTS WITH LUPUS NEPHRITIS

Zahvaćanje bubrega teška je komplikacija sistemskog eritemskog lupusa, praćena visokim pobolijevanjem i smrtnošću. Do razvoja lupusnog nefritisa dolazi u do 60% oboljelih, a unatoč primjeni novih i potentnijih terapijskih protokola u 5 do 22% ove specifične populacije razvije se završni stadij kronične bubrežne bolesti unutar 15 godina od postavljanja dijagnoze. Kako je SLE ponajprije vezan uz mlađu životnu dob, izuzetno je važno odabrati optimalan modalitet nadomještanja bubrežne funkcije. Brojne su studije provedene ne bi li se odgovorilo na kontroverzna pitanja vezana uz ovu specifičnu populaciju. Veća sklonost infekcijama, rizik od povratka osnovne bolesti u presadak, nedefinirani kriteriji praćenja aktivnosti bolesti nakon transplantacije te veća učestalost epizoda odbacivanja i trombotskih događaja rizični su čimbenici zbog kojih se ovoj skupini dugo vremena onemogućavalo liječenje transplantacijom. Rezultati studija nedvojbeno pokazuju da je dugoročno preživljenje podjednako u liječenih hemodijalizom i peritonealnom dijalizom, no transplantacija bubrega nametnula se kao mnogo bolja metoda koja omogućava dulje preživljenje i veću kvalitetu života, umanjujući istodobno aktivnost samog SLE-a. Iako postoje brojna neistražena i neodgovorena pitanja vezana uz zbrinjavanje ove imunosno vrlo osjetljive i zahtjevne skupine bolesnika, pažljiva skrb prije i nakon transplantacije te uska suradnja nefrologa i imunologa omogućavaju dobar ishod uz znatno povećanje kvalitete života.Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE), associated with high morbidity and mortality. Up to 60% of SLE patients develop LN, and despite novel and potent therapeutic regimens, 5 to 22% develop end-stage renal disease within 15 years of diagnosis. While LN primarily affects younger individuals, it is important to choose optimal method of renal replacement therapy for those who develop end-stage renal disease. Numerous studies were carried out trying to solve problems of treatment of patients with LN. Increased risk of infections, disease recurrence in renal allograft, undefined criteria for follow-up of disease activity after transplantation, as well as higher incidence of rejection episodes and thrombotic events are well known risks which have postponed and restricted access to transplantation for patients with LN for long-time. However, numerous studies have demonstrated similar long-term survival in patients treated with haemodialysis or peritoneal dialysis, with clear superiority of renal transplantation regarding the prolonged survival and better quality of life for SLE patients. Many questions are still waiting for answers. Close cooperation between nephrologists and immunologists provides the best treatment for SLE patients with end-stage renal disease