Thomas W. Heinrich

Psychiatric Issues in Solid Organ Transplantation

&NA; The identification and treatment of psychiatric comorbidity in patients undergoing solid organ transplantation present a unique opportunity for psychiatric involvement in the care of medically complex patients. The burden of psychiatric illness in patients awaiting transplant and following transplant is significant and associated with potential morbidity and mortality. Possibilities for psychiatric liaison with our colleagues in transplant medicine and surgery start with the comprehensive psychiatric evaluation that is often performed with potential organ recipients and donors. The vital role of the psychiatrist continues following transplantation, as adjustment is often a stressful experience with associated psychiatric comorbidity. The treatment of psychiatric illness in patients following transplantation requires an understanding of the immunosuppressant medications that patients may be taking, coupled with an awareness of the associated risks of adverse effects and drug‐drug interactions.

Clozapine-Induced Myocarditis: Prevention and Considerations in Rechallenge

The incidence of clozapine-induced myocarditis is 0.2%–3%, and it can be life threatening, with a mortality rate as high as 50%. It can be subtle in its presentation, with the most common symptoms including flulike symptoms, fever, fatigue, and dyspnea. Approximately 80% of cases of clozapineinduced myocarditis occur within 4 weeks of drug initiation, and 90% occur within 8 weeks. The diagnosis is typically guided by a preponderance of clinical evidence, as even the diagnostic gold standard of endomyocardial biopsy has limited sensitivity and specificity. We present the case of a 44-year-old woman who developed clinical signs and symptoms of clozapineinduced myocarditis, approximately 2 weeks following the initiation of clozapine treatment for psychosis.

Recommendations for Training Psychiatry Residents in Psychosomatic Medicine

BACKGROUND The Accreditation Council of Graduate Medical Education (ACGME) mandates that residents in psychiatry training programs learn to provide psychiatric consultation to other medical and surgical services. The ACGME, however, offers little information to instruct academic faculty and institutions to what constitutes a quality educational experience in psychosomatic medicine/consultation-liaison psychiatry for the resident trainee. METHODS These recommendations were developed through a collaborative process between educators in C-L psychiatry and members of the Academy of Psychosomatic Medicines Residency Education Subcommittee. RESULTS This manuscript provides a broad framework for what constitutes a well-rounded clinical and academic resident rotation on psychiatric consultation-liaison services. A rotation that is viewed positively by residents is important as it likely provides a foundation for a growing interest in Psychosomatic Medicine and the development of future fellows and subspecialty trained physicians.

Predictive factors of daily opioid use and quality of life in adults with sickle cell disease

ABSTRACT Objectives: In adults with sickle cell disease (SCD), pain often necessitates opioid use. Few studies have examined the relationship between opioid use and health-related quality of life (HRQOL) in adults with SCD. We tested the hypothesis that higher doses of opioids are associated with worse HRQOL. Methods: A cross-sectional cohort study was performed in adults with SCD who completed standardized and validated HRQOL questionnaires: Patient Health Questionnaire-15 (PHQ-15), Patient Health Questionnaire-9 (PHQ-9), Medical Outcome Study 36 Item Short Form (SF-36), and Generalized Anxiety Disorder questionnaire (GAD-7). Daily outpatient opioid dose was converted into morphine milligram equivalents (MME) and categorized as < 90 mg/day or ≥ 90 mg/day. Subjects questionnaire scores were compared by opioid dose. Results: Ninety-nine adults completed questionnaires. The majority had HbSS and median age was 30 years. The median MME was 80 mg/day. When the association between HRQOL and opioid dose was compared, those prescribed ≥ 90 MME had significantly lower SF-36 subscale scores in 7 of 8 domains, and significantly higher severity scores in the PHQ-15, GAD-7, and the PHQ-9 in comparison those prescribed < 90 MME. Using a multivariable regression tree analysis, in addition to the presence of chronic pain, mental health, physical health, and somatic burden were key predictors of ≥ 90 MME opioid use. Conclusion: Higher daily opioid dose is associated with chronic pain. Among those with chronic pain, opioid dose ≥ 90 MME is associated with worse HRQOL.

Pharmacologic and nonpharmacologic approaches to the prevention and management of delirium

Delirium is a syndrome of neuropsychiatric signs and symptoms that can accompany virtually any serious medical condition. Delirium is characterized by a disturbance of attention and awareness, as well as variety of other aspects of cognition that develops over a short period of time in response to another medical condition. It is an independent risk factor for increased morbidity and mortality and is associated with increased lengths of stay and costs of care. Despite this, it frequently goes unrecognized, and debate continues about the best prevention and treatment strategies. This article will review the current best practices for the prevention and treatment of delirium and how collaborative care can aid in improving outcomes and minimizing adverse events for patients suffering from delirium.

Dementia: A complex disease with multiple etiologies and multiple treatments.

As the population of the United States ages, the rates of dementia are also likely to increase. Clinicians will, therefore, likely be asked to evaluate and treat an escalating number of patients experiencing a decline in multiple domains of cognitive function, which is the hallmark of neurocognitive disorders. It is also probable that clinicians will be confronted with management dilemmas related to the myriad of psychological and behavioral problems that often occur as a consequence of the neurocognitive impairment. In fact, these behavioral and psychological issues might be the initial symptoms that lead the patient to present to the clinician. Dementia has multiple potential etiologies, and a careful diagnostic assessment is imperative to best characterize the specific type of dementia impacting the patient. This is important, as knowing the type of dementia helps the clinician choose the most effective treatment. Potential treatments should be interdisciplinary in scope, patient/family-centered, and may include both nonpharmacologic and pharmacologic treatments.

Ingestion of Hawaiian Baby Woodrose seeds to obtain a legal high.

The use of plant material to experience a hallucinogenic effect has been popular for centuries. This practice has become prevalent among adolescents but has only recently been noted in the professional literature. It is known as a legal high and the products are often marketed as such.They canbepurchased via the Internet or in local shops inmost countries in theworld, including the United States. The following case presents an acute ingestion of Hawaiian Baby Woodrose (HBW) seeds.