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Sjögren's syndrome (SS) is a common medical condition which may produce psychiatric disturbances. Psychoactive medications treat psychiatric symptoms, but leave the underlying process unaffected.
To emphasize that psychiatric disorders in primary SS constitute an indisputable clinical reality that each practitioner must be able to recognize and treat.
A systematic review on psychiatric manifestations of SS and two case-reports of mental disorder as clinical presentation of primary SS.
Psychiatric manifestations in primary SS are common and can occur not only during its course, but also at onset of the autoimmune syndrome. A better adapted prescription of corticosteroids and/or immunosuppressive agents (together with specific psychotropic traetments) can induce to a rapid relief of psychiatric dysfunction.
Psychiatrists should keep in mind that primary SS is a potential cause of mental disorders when examining patients with multiple somatic complaints and psychiatric symptoms.
The diagnostic boundaries of social anxiety disorder (SAD) are still controversial and recent evidence suggests that the condition could be better understood as a continuum of severity, rather than a strictly circumscribed entity. Current neuroanatomical theories on SAD support the involvement of limbic structures in its pathophysiology, with an emphasis on the amygdala. Thus, the objective of this study was to investigate the hypothesis of volumetric alterations in the amygdala of subjects in different points of the social anxiety spectrum.
The sample consisted of patients with generalized SAD (n=17), subthreshold SAD (increased social anxiety without avoidance; n=13), and healthy controls (n=15). Participants underwent structural magnetic resonance scans and the volume of the bilateral amygdala was manually determined.
Significantly greater volumes of bilateral amygdala were found in socially anxious individuals. Amygdala volumes of subthreshold SAD participants fell between the values found for generalized SAD and healthy controls.
Individuals suffering from SAD have greater amygdala volumes compared to controls and this difference seems to be in agreement with the theoretical conception of SAD as a severity continuum and not as a circumscribed nosological entity.
Paraphrenia is a chronic psychotic disorder similar to paranoid schizophrenia, but with a better-preserved affect and rapport and a much less personality deterioration. It was at first systematically described by Kraepelin in 1913 to define a group of psychotic patients who exhibited characteristic symptoms of dementia praecox, but with minimal disturbances of emotion and volition, and marked delusions. After the publication of Mayer-Gross's report in 1921, the view to differentiate paraphrenia from schizophrenia was considered to be unfounded and the term ”paraphrenia” was not included in the current DSM-IV-TR diagnostic criteria. Consequently, now this disorder is diagnosed infrequently. However, several authors suggest that the concept of paraphrenia has not lost its usefulness. It seems to be that some psychiatrists recognize the illness, but labelled it as ”atypical psychosis”, ”schizoaffective disorder”, ”delusional disorder” or ”psychotic disorder not otherwise specified” for the lack of a better diagnostic category. Very few systematic studies on paraphrenia have been conducted in the past 70 years. Aim of this work is to describe a case of chronic delusional psychosis who meets the Ravindran's modern diagnostic criteria for ”paraphrenia redefined”, suggesting that it is possible to define and recognize the illness if the practitioners are induced to use a viable diagnostic entity. Further research would benefit paraphrenia and schizophrenia patients.
To construct and test the validity of a new psychometric questionnaire to assess psychological impact of facial lipoatrophy (ABCD-F), that is the most stigmatizing feature of HIV-related lipodystrophy.
Construction: The development went through Focus groups and Content Validity, Item reduction and Exploratory Factor Analysis.
Validation: ABCD-F questionnaire was administered together with ABCD and MOS HIV questionnaires. The Cronbach's Alfa was used to test internal consistency, while convergent validity and divergent validity were analyzed by the correlations with MOS, ABCD items and BMI and CD4 counts respectively.
42 HIV+ people participated to focus groups. In the EFA the 17 Items were aggregated around psychological distress and role functioning domains.
ABCD-F showed high internal consistency (Chronbach's alpha = 0.95). Both convergent and divergent validity were confirmed. ABCD-F scores were highly correlated to Physical Health Summary (B 0.59; 95% [CI] 0.35; 0.84; p< 0.0001), Mental Health Summary (B-1.54; 95% [CI] 1.15; 1.93; p< 0.0001), and weakly correlated to CD4 count (B-0.02; 95% [CI] -0.01; 0.06; p=0.54) and HIV viral load (B-0.004; 95% [CI] -2.69; 2.69; p=1.00).
ABCD-F is a valid and reliable questionnaire to assess psychological impact of facial lipoatrophy (FLA).
ABCD-F may result as a useful tool both in clinical and research settings: it's able to identify people experiencing greater psychological impact due to FLA. It may become an objective instrument to evaluate priority and efficacy of plastic surgery to treat lipodystrophy. In research setting may be used to compare different populations or different treatments of FLA.
The project “Social Point” deals in promoting integration of Mental Health Service recipients within contexts of social relationship, voluntary work and community activism. The project is still taking place in the district of Modena.
Assessment of the effectiveness of the project SP: production of a change in quality of life; development of purposeful relationships out of families and health services; development of Mental Health Service recipients’ awareness of being not only a user of the health service but also a resourceful person; change of method and approach within relationship between Mental Health and community and public services.
At the beginning and at the end of the integration courses (autumn/winter 2010 and after 6–8 months), both individuals and collectives, every Mental Health Service recipient was asked to fill in a form with socio-demographic characteristics and the WHOQOL-bref. A social network diagram was subsequently drawn.
At the end of the research (September 2010) joining courses directed to the development of social relationship is forecast to improve the quality of life of the recipients, to increment purposeful relationships and to strengthen empowerment of persons with mental disease by promoting a different project of life no more illness-based but resource-based.
The study will provide evidences about the performance of the project with regard to the promotion of the social integration of citizens with mental disease in contexts, to the empowerment and to the promotion of processes of social.
To evaluate the clinical and functional effects of cannabis abuse in patients at First Episode Psychosis (FEP) referring to Community Mental Health Centre (CMHC) “Bologna Ovest” and in patients admitted with a diagnosis of psychosis at the Modena Emergency Psychiatry Ward (EPW).
All FEP patients, aged 18-35, referring to CMCH “Bologna Ovest” in a 6-years period were evaluated and followed-up at 3 and 12 months. Of the 1559 psychiatric admissions at the Modena EPW in a 3-year period, those with a positive history for substance abuse were selected.
Among the 88 Bologna Ovest FEPs, 32% were cannabis abusers (FEP-c). In Bologna, FEP-c were more frequently natives (23.39% vs 31.13%; c sq=5.1; p=0.02) single (26.38% vs 0,0% c sq=7.3, p=0.007) and unemployed (13.50% vs 18.32%, c sq=2.4, p=0.1). Non FEP-c did not use any other drug (0.0% vs 26.1%, c sq=77.5; p< 0.001). A trend towards higher prevalence of hospital admission at follow-up was found for FEP-c (4.20% vs 2.4%, c sq=3.8, p=0.07). 22.0% of patients admitted at the Modena EPW had a positive history for substance abuse: of these, 7% were diagnosed with paranoid schizophrenia, which significantly correlated with the use of cannabinoids (alone or in association).
Our results enlighten that cannabis use is frequent among psychotic patients admitted to hospital and worsens clinical course of FEP patients, consistently with previous evidence (Hambrecht & Hafner, 1996; Hafner et al., 2004).
Recent reviews of evidence-based guidelines for the clinical management of Bipolar Disorders (BD) have recommended that “all patients with BD should be offered group or individual psychoeducation” to prevent relapse, improve treatment adherence, quality of life and functioning.
The present study aimed at evaluating the psychoeducation in routine mental health.
One hundred and two outpatients were recruited from two Italian DMHs. Inclusion criteria were a lifetime diagnosis of BD type I or II assessed by SCID-I, being euthymic for at least 3 months. Exclusion criteria were a DSM-IV Axis I comorbidity, mental retardation (IQ < 70), organic brain damage. All subjects received standard psychiatric care, with standard pharmacological treatment; one group received additional 21 weekly sessions of psychoeducation group, according to Colom and Vieta model.
Data show that the number of patients hospitalized during the 1-year follow-up, the mean number of hospitalizations per patient and the mean number of days in hospital were significantly lower for psychoeducated patients.
Our study supports the view that group psychoeducation is an efficacious intervention to prevent patients’ hospitalization and decrease hospital days in pharmacologically treated patients with bipolar disorder, also in routine clinical settings. The results seem to confirm that the psychoeducation promotes an improvement in the course of illness, avoiding acute phases, and producing a greater stabilization of the disease and consequently an improvement in quality of life in people with BD.
The Consultation-Liaison Psychiatry Service of the Modena General Hospital collaborates regularly with the Cardiology Clinic, within the Woman Wellness Project (WWP). Aim of this collaboration is detection and prevention of post-menopausal correlated diseases, including psychiatric syndromes.
To investigate the association between cardiovascular risk factors (BMI, blood pressure, hyperglycemia, hypertrygliceridemia) and psychiatric symptoms in peri-post menopausal.
Ecological study. Data between January 2008 and December 2012 were collected. Correlations, logistic regessions and categorial regressions were performed with STATA.
675 outpatients attended the WWP. 90 (13.3%) were referred to the psychiatrist; 9 refused the examination. Of the remaining 57.7% had a positive psychiatric history and 22.03% already receaved a psychiatric therapy. 40.6% had at least two medical diseases, mainly: overweight (54.2%), hypertension (40.7%) and dyslipidemia (49.1%). After psychiatric consultation emerged that: 11.9% had anxiety symptoms, 27.1% had depressive symptoms and 47.5% presented both anxiety and depressive symptoms. Only 7 patients (11.9%) had a negative psychiatric examination. The regression analysis pointed out no significant association between the cardiometabolic risk-factors and the psychiatric symptomatology. Differently, the outcome at the end of the psychiatric consultation was associated with BMI (r = −.26; p = .05) and heart rate (r = .33; p = .01).
Heart rate and BMI emerge as factors associated with the psychiatric symptomatology presented by the patient. This finding is consistent with previous researches. The absence of significant associations at the regression analysis could be explained by the small sample considered in the present study.
The term ‘revolving door (RD) phenomenon” was coined to define recurrent hospitalizations of chronically ill patients after closure of psychiatric hospitals and implementation of community treatments.
Continued readmissions require a large portion of Mental Health Departments’ resources.
To analyze the RD phenomenon in an acute psychiatric ward during a 5-year period.
We retrospectively selected all patients with 3 or more hospitalizations per year from 01/01/ 2009 to 31/12/2013 in SPDC-Modena Centro. From their medical records we collected selected variables, potential predictors of RD phenomenon. Data were statistically analyzed.
In the 5-year period, a sample of 105 patients (47 females, 58 males) with an average age of 40.25 years (± 13.47 SD), 5.68 % of all inpatients (n = 1850), realized 778 hospitalizations, 23.94 % of all admissions (n=3250). The most frequent reason for admission was ‘worsening of psychiatric symptomatology” (55.27%). The most frequent diagnoses at discharge were ‘Schizophrenia” (41.26%) and ‘Personality Disorders” (25.32%). Most of RD patients (87%) were Italian, only 15 % were employed and 50 % lived with family. The mean duration of RD hospitalizations (12.23 days ± 18.37 SD) was statistically significantly different from all others in the 5-year period (10.39 days ± 11.09 SD, p=0.0008, t test) as was the frequency of compulsory admissions (RD hospitalizations 18% vs. 26% all others, chi2, p<0.001).
Our RD patients represented a small percent of all inpatients but required many and long hospitalizations, probably due to severe and disabling illness.
Evidence has suggested that immune imbalance is involved with bipolar disorder (BD); however, its precise mechanism is poorly understood.
This study investigated whether biochemical changes in the serum from BD patients could modulate the phenotype of macrophages.
Eighteen subjects with BD and healthy individuals (n = 5) were included in this study. The human monocyte cell line U-937 was activated with PMA (phorbol 12-myristate 13-acetate) and polarization was induced with RPMI-1640 media supplemented with 10% serum from each patient for 24 h. Gene expression of selected M1 and M2 markers was assessed by qPCR.
Macrophages exposed to serum of manic and depressive BD patients displayed an increase of IL-1β (6.40 ± 3.47 and 9.04 ± 5.84 versus 0.23 ± 0.11; P < 0.05) and TNF-α (2.23 ± 0.91 and 2.03 ± 0.45 versus 0.62 ± 0.24; P = 0.002 and P = 0.004, respectively) compared to remitted group. In parallel, U-937 macrophages treated with serum of patients in acute episode displayed a down-regulation of CXCL9 (0.29 ± 0.20 versus 1.86 ± 1.61; P = 0.006) and CXCL10 expression (0.36 ± 0.15 and 0.86 ± 0.24 versus 1.83 ± 0.88; P < 0.000 and P = 0.04) compared to remitters.
Our results are consistent with previous studies showing that changes in peripheral blood markers could modulate M1/M2 polarization in BD. The evidence of macrophages as source of inflammatory cytokines might be helpful to unravel how the mononuclear phagocyte system can be involved in the etiology of BD.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Mindfulness based interventions (MBIs) have shown efficacy in improving psychological symptoms including depression and anxiety in cancer patients (pts). The study aimed to explore feasibility and reproducibility of MBIs in an Italian Cancer Centre measuring biochemical and psychological parameters.
In this pilot prospective case-control study, we recruited newly diagnosed pts receiving adjuvant chemotherapy (CT). A MBIs program was designed consisting of 2.5 hours weekly for 8 weeks and, including meditation, yoga and body scan. Material for 45 minutes (mn) home daily practice was provided. Primary endpoint was to evaluate feasibility. Secondary endpoints were assessment of quality of life (QoL), psychological and biochemical outcomes of stress, tested at baseline (W0), W4, W8, W24, W48. PSS (Perceived Stress Reduction), POMS (profile of mood states scores), EuroQoL (EQ-5D-3L) were administered.
Ten pts underwent MBIs program arm. We present preliminary results, while data of control arm are being collected. All pts were female, two pts (20%) dropped out. Median age was 56 years. All received adjuvant CT, 5/8 received radiotherapy and hormone therapy. Mean of sessions attending was 6.8 (76%). Median daily practice was 30 mn. EQ-5D item for depression and anxiety showed decreasing trend in mean score from moderate to light (P = 0.15) and significant improvement of auto-perceived QoL was observed comparing W0 and W8 (P = 0.02)
In a sensitive setting such as start CT, we found high pts compliance to MBIs. Improvement in self-perceived QoL after starting program was found and comparing anxious-depressive symptoms outcomes with control arm is still needed.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Postgraduate medical trainees experience high rates of burnout, but evidence regarding psychiatric trainees is missing. We aim to determine burnout rates among psychiatric trainees, and identify individual, educational and work-related factors associated with severe burnout.
In an online survey psychiatric trainees from 22 countries were asked to complete the Maslach Burnout Inventory (MBI-GS) and provide information on individual, educational and work-related parameters. Linear mixed models were used to predict the MBI-GS scores, and a generalized linear mixed model to predict severe burnout.
This is the largest study on burnout and training conditions among psychiatric trainees to date. Complete data were obtained from 1980 out of 7625 approached trainees (26%; range 17.8–65.6%). Participants were 31.9 (SD 5.3) years old with 2.8 (SD 1.9) years of training. Severe burnout was found in 726 (36.7%) trainees. The risk was higher for trainees who were younger (P < 0.001), without children (P = 0.010), and had not opted for psychiatry as a first career choice (P = 0.043). After adjustment for socio-demographic characteristics, years in training and country differences in burnout, severe burnout remained associated with long working hours (P < 0.001), lack of supervision (P < 0.001), and not having regular time to rest (P = 0.001). Main findings were replicated in a sensitivity analysis with countries with response rate above 50%.
Besides previously described risk factors such as working hours and younger age, this is the first evidence of negative influence of lack of supervision and not opting for psychiatry as a first career choice on trainees’ burnout.
Recent evidences have consistently reported lower glutamate (Glu) levels in various brain regions, including the medial prefrontal cortex (mPFC), in chronic schizophrenia but findings in the early (EP) or in the prodromal phase of the disorder are equivocal. Although regular cannabis use has been associated with an increased risk of subsequent psychosis and with a perturbed Glu signalling, to date, the critical question of whether or not Glu abnormalities exist in EP and are related to cannabis use remains unanswered. Magnetic resonance spectroscopy was used to measure [GlumPFC] of 35 EP subjects (18 of whom were regular cannabis users) and 33 healthy controls (HC). For correlative analysis, neuropsychological performances were scored by a comprehensive cognitive battery. [GlumPFC] was lower in EP users comparing to both HC and EP non-users (P = 0.001 and P = 0.01, respectively), while no differences were observed between HC and EP non-users. In EP users Glu declined with age (r = −0.46; P = 0.04) but this relationship was not observed in non-users. Among neuropsychological profiles, working memory was the only domain that differentiates patients depending on their cannabis use, with users having poorer performances. In summary, our research revealed that cannabis use in EP is associated with Glu decreased levels, which are normally not seen in the early phase of the disorder. This finding is in line with previous 1H-MRS studies in cannabis users without a psychotic disorder and sheds light for the role of cannabis use in the progression of the disease.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Recent evidence points to a critical role of redox dysregulation induced oxidative stress in the pathophysiology of early phases of schizophrenia. An add-on trial with n-acetyl-cysteine (NAC) led to a reduction in negative symptoms in chronic schizophrenia patients. Aim of this study was to explore impact of addition of NAC to standard treatment in early psychosis (EP) patients.
Double-blind, randomized, placebo-controlled trial of addition of NAC, 2700 mg daily, to antipsychotic treatment over 6 months. Monthly assessment of PANSS, GAF, SOFAS and antipsychotics treatment; quantification of brain glutathione levels (GSHmPFC) by 1H-magnetic-resonance-spectroscopy and of blood cells glutathione (GSHBC) and glutathione peroxidase activity (GPxBC) as marker of oxidation status at the beginning and end of treatment.
Overall, 63 patients were included. Spectroscopy data showed that GSHmPFC increased by +23% in the NAC group, while it tended to decrease by −5% in the placebo group (P = 0.005). No significant difference between NAC and placebo was observed on global changes in negative symptoms, positive symptoms or functional outcome. However, in patients with high-baseline oxidation status (GPxBC>22.3U/gHb), subgroup explorations revealed an improvement of positive symptoms over time compared to patients with low-baseline GPx (P = 0.02).
While addition of NAC induced an increase of brain GSH, it had no impact on symptomatic and functional outcome in EP patients. However, in patients with high oxidation status, addition of NAC leads to significantly greater improvement in positive symptoms. Future studies on antioxidant interventions in EP should consider biomarker-guided treatment.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Several elicitors, stimulating induced resistance mechanisms, have potential in preventing or mitigating pathogen infections. Some of these compounds, triggering the production of jasmonic acid (JA), a precursor of herbivore-induced plant volatiles, could also play a central role in indirect resistance to pest species, by improving beneficial arthropod performance, and necrotrophic pathogens. In the current work, Trichoderma gamsii/T. asperellum and silica gel treatments – alone and in combination – were studied to evaluate the plant defence mechanism on grapevines (Vitis vinifera L.) by laboratory and field trials. JA production level was measured before and after Plasmopara viticola infection on potted vines. JA production induced by silica gel was higher than that caused by Trichoderma before infection. In Trichoderma-treated plants, JA production increased after P. viticola inoculation. In vineyard field trials, Mymaridae (Hymenoptera: Chalcidoidea) showed higher captures in transparent sticky traps on silica gel-treated plants, in comparison with control. On the other hand, no significant attraction was detected for Ichneumonoidea and other Chalcidoidea in silica gel and T. gamsii/T. asperellum-treated plants. The potential effects of elicitors are discussed, in the frame of attract and reward strategy.
Intake in sugar-rich diets can be limited either via rumen fill or excessive rumen fermentation and source of non-fibre carbohydrate (NFC) in the diet can affect both factors. The aim of the current study was to quantify the effect of partially replacing ground maize (GM) with steam-rolled maize (SRM) or pelleted citrus pulp (PCP) at two concentrate levels in sugarcane-based diets on digestibility, rumen ecosystem and metabolism of Nellore steers. Six rumen-cannulated steers were assigned to a 6 × 6 Latin square, replicated in time, in a 2 × 3 factorial arrangement of treatments with two levels of concentrate (600 or 800 g concentrate/kg dry matter [DM]) and three NFC sources. Each steer within a period was considered an experimental unit. Feeding more concentrate increased total tract digestibility of organic matter and decreased fibre intake and passage rate. It also reduced rumen populations of Fibrobacter succinogenes and Streptococcus bovis and increased Ruminococcus flavefaciens. Substituting PCP for GM increased rumen pH, acetic acid and organic matter digestibility. Feeding PCP also reduced R. flavefaciens and R. amylophilus rumen populations. Substituting SRM for GM increased starch digestibility and rumen propionic acid, but decreased rumen ammonia concentration. Feeding SRM increased rumen populations of Megasphaera elsdenii with the high-concentrate diet but reduced Ruminococcus albus populations at both concentrate levels. In conclusion, partial replacement of GM by PCP decreased intake in sugar-rich diets, while increasing total tract neutral detergent fibre digestibility. Replacement of GM with SRM increases rumen fermentation and total tract digestibility of starch.
Replacing ground maize (GM) with steam-rolled maize typically increases feed efficiency in maize-silage-based diets. However, little is known about optimal carbohydrate supplementation in sugarcane silage-based diets. The objective was to quantify the effect of partially replacing GM with steam-rolled maize (SRM) or pelleted citrus pulp (PCP) at two concentrate levels (600 or 800 g/kg DM) in sugarcane-based diets on feeding behaviour, performance and blood parameters of finishing Nellore bulls. One hundred and eight young bulls were allocated to 36 pens in a randomized block design and fed for 84 d. Feeding 800 g/kg concentrate decreased time spending eating and ruminating, but improved G:F ratio, hot carcass weight and carcass dressing, compared to 600 g/kg concentrate. Bulls fed SRM and PCP diets with 600 g/kg concentrate had lower intake compared to GM. Both final weight and average daily gain decreased when bulls were fed PCP and SRM with 600 g/kg concentrate compared to GM diets, and when fed with PCP and 800 g/kg concentrate. Substituting PCP for GM decreased gain efficiency, carcass weight, rumination time and intake efficiency, indicating that the bulls consumed less feed per hour spent eating. Substituting SRM for GM increased backfat thickness and blood urea concentration. In conclusion, the replacement of GM with PCP reduces intake and enhances selection against large particles, decreasing rumination, performance and final carcass weight and dressing. Replacement of GM with SRM increases blood urea and fat deposition, with no impact on performance.
The crystal structure of tlapallite has been determined using single-crystal X-ray diffraction and supported by electron probe micro-analysis, powder diffraction and Raman spectroscopy. Tlapallite is trigonal, space group P321, with a = 9.1219(17) Å, c = 11.9320(9) Å and V = 859.8(3) Å3, and was refined to R1 = 0.0296 for 786 reflections with I > 2σ(I). This study resulted from the discovery of well-crystallised tlapallite at the Wildcat prospect, Utah, USA. The chemical formula of tlapallite has been revised to (Ca,Pb)3CaCu6[Te4+3Te6+O12]2(Te4+O3)2(SO4)2·3H2O, or more simply (Ca,Pb)3CaCu6Te4+8Te6+2O30(SO4)2·3H2O, from H6(Ca,Pb)2(Cu,Zn)3(TeO3)4(TeO6)(SO4). The tlapallite structure consists of layers containing distorted Cu2+O6 octahedra, Te6+O6 octahedra and Te4+O4 disphenoids (which together form the new mixed-valence phyllotellurate anion [Te4+3Te6+O12]12−), Te4+O3 trigonal pyramids and CaO8 polyhedra. SO4 tetrahedra, Ca(H2O)3O6 polyhedra and H2O groups fill the space between the layers. Tlapallite is only the second naturally occurring compound containing tellurium in both the 4+ and 6+ oxidation states with a known crystal structure, the other being carlfriesite, CaTe4+2Te6+O8. Carlfriesite is the predominant secondary tellurium mineral at the Wildcat prospect. We also present an updated structure for carlfriesite, which has been refined to R1 = 0.0230 for 874 reflections with I > 2σ(I). This updated structural refinement improves upon the one reported previously by refining all atoms anisotropically and presenting models of bond valence and Te4+ secondary bonding.
Let (R, 𝔪) be a Noetherian local ring and I an arbitrary ideal of R with analytic spread s. In  the authors proved the existence of a chain of ideals I ⊆ I[s] ⊆ ⋅⋅⋅ ⊆ I such that deg(PI[k]/I) < s − k. In this article we obtain a structure theorem for this ideals which is similar to that of K. Shah in  for 𝔪-primary ideals.