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Severe and life-threatening hypercalcaemia can develop in haemodialysis patients dialysed against a dialysate with a high calcium concentration, the so-called hard water syndrome. Here we describe the development of hard water syndrome in 30 patients following sequential failure of the reverse osmosis unit and water softeners. Serum calcium levels rose from 2.43 ± 0.19 to 3.92 ± 0.51 mmol/L after exposure. All patients required emergency haemodialysis and four acutely deteriorated, one of whom was 24 weeks pregnant. This is the largest reported series of patients affected by this rare and severe condition. This event led to the introduction of processes to minimize future risks.

Acute kidney injury (AKI) is common in hospitalised patients but is known be suboptimally managed; the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report in 2009 identified significant failings in AKI care. An audit, using standards suggested by the NCEPOD report, of all adult inpatients with AKI in a large central-London NHS hospital in a 7-day period in 2011 showed poor recognition and management of AKI. In response, an AKI ‘care bundle’ was developed and deployed throughout the hospital along with a programme of enhanced education. Re-audit in 2013 showed that AKI was significantly more likely to have been recognised by the clinical team than in 2011, and patients with AKI were significantly more likely to have had fluid status clinically assessed and nephrotoxic medication stopped in 2013 than in 2011. There was no significant improvement in fluid administration if assessed as hypovolaemic and compliance with the guideline for prevention of contrast nephropathy. In 2011, all audit measures were met in 3.7% of patient-days versus 8.4% in 2013. More in-depth work is necessary to better understand the factors which limit optimal care.

BackgroundDifficulties with prospective mental images are associated with adolescent depression. Current treatments mainly focus on verbal techniques to reduce negative affect (e.g. low mood) rather than enhancing positive affect, despite anhedonia being present in adolescents. We investigated the concurrent relationships between the vividness of negative and positive prospective mental imagery and negative affect and positive affect; and examined whether negative and positive prospective mental imagery moderated the impact of recent stress (COVID-19-linked stress) on negative and positive affect.Methods2602 young people (12–25 years) completed the Prospective Imagery Task and self-reported on symptoms of negative affect, anhedonia and COVID-19 linked stress.ResultsElevated vividness of negative future mental imagery and reduced vividness of positive future mental imagery were associated with increased negative affect, whereas only reduced vividness of positive future imagery was associated with increased symptoms of anhedonia. Elevated vividness of negative future images amplified the association between COVID-19 linked stress and negative affect, while elevated vividness of positive future images attenuated the association between COVID-19 linked stress and anhedonia.ConclusionsFuture mental imagery may be differentially associated with negative and positive affect, but this needs to be replicated in clinical populations to support novel adolescent psychological treatments.

Interventions targeting anhedonia in depression demonstrate encouraging results in adults but are lacking for adolescents. Here, we have adapted a brief imagery-based intervention (IMAGINE), which has shown promising results in reducing symptoms of depression in young people, to focus specifically on reducing symptoms of anhedonia (IMAGINE-Positive). We augment positive mental imagery generation with techniques to upregulate positive affect. Eight participants completed the four-session intervention. Data on feasibility and acceptability were collected. Questionnaires of symptomology and cognitive mechanisms (e.g. depression, anhedonia and future imagery vividness) were administered at pre-intervention, post-intervention and 3-month follow-up. The intervention was feasible to deliver and acceptable to participants. There was a large reduction in depression symptom scores from pre- to post-intervention ( d  = 1.12) and 63% of participants showed reliable improvement (RI), which was maintained at follow-up ( d  = 2.51, RI = 86%). Although there were only small reductions in anhedonia from pre to post ( d  = 0.38, RI = 0), there was a large reduction from pre to follow-up ( d  = 1.28, RI = 29%). There were also large increases in positive future imagery vividness (post, d  =  − 1.08, RI = 50%; follow-up, d  =  − 2.02, RI = 29%). Initial evidence suggests that IMAGINE-Positive is feasible and acceptable and may have clinical utility, but future randomised controlled trials are needed to further evaluate efficacy.